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SUBCUTANEOUS 
HYDROCARBON   PROTHESES 


The  Grafton  Medical  Books 


The  Surgery  of  the  Heart  and  Lungs 

By  B.  M.  Ricketts,  M.D.  . 
8vo.     Cloth,  illustrated,  ^2.50  net  (carriage  32c.) 


A  Compend  of  Operative  Gynecology 

By  W.  S.  Bainbridge,  M.D.,  and  H.  D.  Meeker,  M.D. 
12  mo.     Cloth,  ^i.oo  net  (postage  sc.) 

Nephritis 

By  S.  W.  Little,  M.D. 
i2mo.     Cloth,  $1.25  net  (postage  loc.) 

The  Journal  of  Cutaneous  Diseases 

Edited  by  A.  D.  Mewbom,  M.D. 
Monthly,  ^54.00  per  year 

Syphilis  in  its  Medical,  Medico-Legal  and 
Sociological  Aspects 

By  A.  Ravogli,  M.D. 
8vo.     Cloth,  illustrated,  $5.00  net  (carriage  extra) 

Subcutaneous  Hydrocarbon  Protheses 

By  F.  Strange  Kolle,  M.D. 
Large  lamo.     Cloth,  illustrated,  J2.50  net  (carriage  extra) 


A.   Supra-Orbital  Vein     G.   Ext.  -  Jugular    Vein     M.  Transverse   Facial  Vein 


B.  Supra-Palpebral 

C.  Angular 
D    Nasal 

E.  Facial 

F.  Temporal 


H.   Post-Auricular 
I.  Occipital  ' 

J.   Post-Ext. -Jugular' 
K.  Sup.  Labial 
L.   Inf.  Labial  ' 


N.   Communicating  Br.  Ophtal 

O.  Angular  Artery 

P.  Ant.  Temporal  " 

Q.   Post, 

R.  Sup.  Coronary  " 


SUBCUTANEOUS 

HYDROCARBON  PROTHESES 


BY 

F.  STRANGE  KOLLE,  M.  D. 

AUTHOR  OF  "  THE  RECENT  RONTGEN    DISCOVERY  "  ;   "  THE  X-RAYS, 
THEIR  PRODUCTION  AND  APPLICATION  "  ;    "  MEDICO- 
SURGICAL  RADIOGRAPHY  "  ;   ETC.,  ETC. 


THE   GRAFTON   PRESS 

PUBLISHERS  NEW  YORK 


Copyright  igo8  by 
F.  STRANGE  KOLLE,  M.  D. 


\<.%'b 


FOREWORD. 

The  object  of  the  author  has  been  to  place  before  the  profes- 
sion a  thoroughly  practical  and  concise  treatise  on  the  subcu- 
taneous employment  of  hydrocarbons  for  the  correction  of  de- 
fects about  the  face,  neck  and  shoulders.  The  importance  of 
this  particular  branch  of  cosmetic  surgery  is  at  the  present  time 
undeniable.  It  has  revolutionized  certain  extensive  operative 
procedures,  especially  in  Rhinoplasty,  giving  results  that  no 
surgeon  could  hope  to  attain  under  the  former  laws  of  surgery. 

The  literature  on  this  subject  is  widely  scattered  and  scanty. 
It  consists  mostly  of  small  detached  papers  or  reports  of  special 
cases  by  different  surgeons  in  different  countries.  The  author 
has  selected  from  the  most  authoritative  sources,  such  of  this 
data  as  he  deemed  necessary  for  a  full  presentation  of  the  evolve- 
ment  of  the  methods  used  at  present,  and  combined  these  with 
the  results  of  his  own  practical  experience  in  several  thousand 
prothetic  operations. 

Great  care  has  been  taken  to  give  as  faithful  representation 
of  the  cases  illustrated  as  possible,  bearing  in  mind  that  the  ac- 
tual cosmetic  improvement  is  greater  than  can  possibly  be  shown 
in  black  and  white. 

The  exponents  in  the  text  refer  to  the  authorities  given  in 
the  back  of  the  book. 

F.  Strange  Kolle,  M.  D. 

18-20  West  25th  Street,  N.  Y. 


SUBCUTANEOUS  HYDROCARBON 
PROTHESES 

Although  the  subcutaneous  employment  of  oil  and  liquefied 
paraffine  has  been  known  for  some  years,  particularly  by  Corn- 
ing ^  who  refers  to  his  use  of  solidifying  oils  in  surgery  in  an 
article  published  in  1891,  no  actual  application  for  prothetic 
purposes  was  made  until  1900,  when  Gersuny  -  first  advocated 
the  method.  In  his  published  report  he  says  that,  "  if  vaseline, 
which  at  the  temperature  of  the  body  has  the  consistency  of 
ointment,  be  liquified  by  heat  and  by  the  means  of  a  Pravaz 
syringe  is  injected  into  dilatable  tissue  of  the  human  body  there 
is  produced,  at  the  site  where  the  injection  is  made,  a  tumefac- 
tion whose  volume  corresponds  to  the  quantity  of  vaseline  in- 
jected. The  reaction  which  results  from  the  procedure  is  in- 
significant and  the  mass  appears  to  rest  without  change  where 
injected." 

This  subcutaneous  method  of  vaseline  injection  he  employed 
in  the  case  of  a  young  girl  to  correct  a  saddle  or  depressed 
nose.  The  operation  was  purely  a  cosmetic  one  and  was  per- 
formed on  the  eighth  day  of  May,  1900,  with  a  very  satisfactory 
result. 

From  the  time  of  the  appearance  of  Gersuny' s  paper, 
"  Ueber  eine  Subcutane  Prothese,"  a  number  of  operators  such 
as  Halban,-'  von  Frisch,"*  Kapsammer,'^  Delangre,^  Rohmer,^ 
Stein  *  and  others,  began  to  follow  the  method  with  gratifying 
results. 


2  HYDROCARBON  PROTHESES 

Pfannenstiel,^  shortly  after,  claimed  that  the  injection  of  vase- 
line was  not  wholly  without  danger  and  that  pulmonary  embo- 
lism had  been  observed  by  him  subsequent  to  its  use.  Mosz- 
kowicz  ^°  denied  the  possibilities  of  such  danger,  although  at  this 
date  it  is  quite  evident  that  there  are  many  objections  to  the 
sole  use  of  sterile  vaseline  for  all  subcutaneous  cosmetic  pur- 
poses where  such  protheses  might  be  indicated. 

Eckstein  ^^  on  the  24th  day  of  July,  1901,  rehearses  these 
objections  and  advocates  the  use  of  "  Hart  paraffine,"  or  par- 
affine  with  a  melting  point  of  57-6o°C.  (i40°F.).  His  method 
was  taken  up  by  Broeckaert,^^  Baratoux,^^  Brindel,^^  Watson 
Cheyne,^^  Walker  Downie,^^  Leonard  Hill,^^  Lake,^*  Scanes 
Spicer,^^  Karewski,^^  and  other  prominent  surgeons  abroad,  and 
by  Parker,^^  Harmon  Smith,^^  Hamilton, ^^  Quinlan,^^  Connell  ^^ 
and  others  in  the  United  States. 

Drs.  Lynch  ^^  and  Heath  ^^  were  the  first  American  physi- 
cians to  place  themselves  on  record  in  the  employment  of  the 
method  of  Gersuny  for  the  correction  of  nasal  deformities. 

Each  of  the  operators  employing  the  now  so-called  Gersuny 
method,  advanced  their  individual  ideas  and  improvements  in 
the  art,  and  those  of  distinctive  merit  will  be  considered  later 
by  the  author  who  has  employed  both  methods-  from  the  time 
of  their  incipiency. 

The  method  of  procedure  in  the  injection  of  vaseline  or 
paraffine  is  practically  similar,  except  for  the  various  ways  in 
which  the  paraffine  of  different  melting  points  is  rendered  liquid. 

INDICATIONS 

The  indications  for  the  Protheses  of  either  method  are  the 
same,  except  where  the  author  advocates  the  use  of  either  one 


HYDROCARBON  PROTHESES  3 

or  the  other  or  a  combination  of  the  two  from  an  experience 
with  over  five  hundred  personally  conducted  cases. 

The  advantages  of  the  Gersuny  method  is  that  the  operation 
is  practically  painless,  causes  no  scar  if  properly  performed  and 
corrects  a  deformity  that  could  not  be  overcome  otherwise  in 
some  cases,  while  in  others  it  would  entail  not  only  difficult  sur- 
gical interferences,  but  subsequently  unsightly  cicatrices  that 
would  render  them  more  objectional  than  the  very  defects  which 
were  intended  to  be  corrected. 

This  is  particularly  true  in  the  cosmetic  correction  of  depres- 
sions about  the  forehead  resulting  from  direct  violence  or  frontal 
sinus  operations,  for  obliterating  habit  furrows,  or  frowns,  be- 
tween the  eyebrows ;  also  to  restore  the  symmetry  of  the 
face  in  hollows  of  the  cheek  due  to  the  removal  of  malignant 
growths,  the  maxillae,  or  when  caused  by  facial  hemiatrophy 
or  a  congenital  or  long-acquired  sinking  in  of  the  cheeks ; 
while  it  may  also  be  employed  with  excellent  result  to  pre- 
vent post-operative  adhesions  about  the  face  after  mastoid 
operations  and  even  to  restore  the  form  of  the  breast  after 
operation  for  malignant  disease  and  the  raising  of  smallpox 
pits. 

Numerous  other  uses  may  be  mentioned,  such  as  elevating  an 
undue  depression  at  the  root  of  the  nose,  raising  sunken  furrows 
below  the  eyes,  obliterating  naso-labial  folds,  angular  droops 
about  the  chin,  rebuilding  weak  or  pronounced  oval  or  peaked 
chins,  filling  hollows  about  the  neck  and  shoulders,  and  in  fact 
anywhere  about  the  body  to  restore  the  contour. 

In  correcting  the  deformities  of  the  nose,  whether  congenital 
or  acquired,  this  method  has  met  an  urgent  and  most  useful 
demand,  so  much  so  that  many  rhinoplastic  operations  of  ex- 


4  HYDROCARBON  PROTHESES 

tensive  delicacy  have  been  thrown  aside  for  this  simpler,  rapid 
and  gratifying  means  of  surgery. 

Not  only  has  it  been  employed  to  restore  the  nasal  line  in 
saddle  noses,  but  also  in  many  other  deformities  of  that  organ 
which  do  not  require  the  removal  of  superabundant  tissue. 

According  to  the  appended  classification  of  nasal  deformities, 
given  by  Roe,^^  it  will  be  seen  that  many  faults  of  that  organ 
may  be  overcome  by  the  method. 


Deformities  of 
the  nose 


Bony  portion 


I  Concave. 
''  Vertical  ■\ 

I  Convex. 

,    I  Spatulated. 
Lateral  -^ 

[_  Defected. 


r  Tip  ^ 


Cartilaginous 
Portion 


L  Wings  ^ 


Excessive     or    defi- 
cient tissue. 
Deviation  from  me- 
I       dian  line. 

f  Collapsed. 


I  Expanded. 


From  the  above  arrangement,  and  taking  each  division  sepa- 
rately, the  author  enumerates  the  applicability  of  the  subcutane- 
ous prothesis,  adding  such  as  are  not  included  in  the  above. 


1.  Vertical  concavity.      An  over-marked  depression  at  the 
site  of  the  bony  structure  and  about  the  root  of  the  nose. 

2.  Lateral  deficiency  of  form  about  the  root  of  the  nose  ex- 


HYDROCARBON  PROTHESES  S 

tending  downward  as  far  as  the  inferior  borders  of  the  nasal 
bones. 

3.  Median  anterior  vertical  concavity  or  saddle  nose  involv- 
ing the  middle  third,  otherwise  the  inferior  and  superior  sec- 
tions. 

4.  Deviations  of  the  cartilaginous  structure  about  the  middle 
third  of  the  nose,  either  unilateral  or  bilateral. 

5.  Deviation  of  the  lobule. 

6.  Deficiency  of  the  lobule. 

7.  Lobular  cleft. 

8.  Subseptal  cleft. 

9.  Collapsed  alae,  unilateral  or  bilateral. 
10.  Retraction  of  subseptum. 

In  these  ten  subdivisions  much  can  be  done  to  bring  about  a 
normal  appearance  of  the  nose. 

PRECAUTIONS 

In  selecting  a  case  for  subcutaneous  injection  the  operator 
must  well  consider  the  methods  to  be  employed,  his  successes 
with  such  methods,  the  importance  and  gravity  of  the  operation, 
the  condition  of  the  patient,  the  extent  of  the  deformity,  the  pe- 
culiarity of  the  patient  and,  particularly,  the  state  of  mind  of 
the  patient. 

While  at  this  date  of  the  use  of  this  method  of  beautifying 
parts  of  the  human  face  we  may  feel  certain  of  the  happy  out- 
come of  an  operation  undertaken  by  the  operator,  he  must  not 
lose  sight  of  the  hypercritical  person  upon  whom  the  work  is  to 
be  done ;  even  with  an  outcome  gratifying  in  the  extreme  from 
a  surgical  standpoint,  the  patient  will  insist,  and  that   in  80^  of 


6  HYDROCARBON  PROTHESES 

all  cases,  to  still  further  improve  them  in  spite  of  the  fact  that 
a  normal  appearance  has  been  attained,  often  leading  the  op- 
erator into  doing  what  he  should  not  do,  and  eventually  undoing 
his  own  excellent  efforts. 

The  author  does  not  mean  to  imply  this  as  a  weakness  on 
the  part  of  the  surgeon,  but  cannot  impress  too  deeply  upon 
him  the  unreasonable  demands  of  a  person  insanely  bent  upon 
having  the  alabaster  cheek  ideal  of  the  poets,  the  nose  of  a  Ve- 
nus, the  chin  of  an  Apollo,  the  neck  of  swan-like  form,  etc. 

The  patient  believes  it  lies  in  the  power  of  the  cosmetic  sur- 
geon to  do  with  their  malformations  as  a  sculptor  would  model 
in  clay  and  will  insist  upon  gaining  their  ideal  beyond  all 
reason. 

Let  the  author  warn  the  operator  against  the  "  beauty  cranks," 
especially  of  those  who  are  just  about  to  engage  in  great  theat- 
rical ventures,  circus  performances  or  "  acts,"  and  very  desir- 
able marriages.  These  are  patients  who  are  not  only  difficult 
to  deal  with,  but  the  first  to  harm  the  hard-earned,  well-de- 
served reputation  of  the  surgeon  and  to  drag  him  into  courts 
for  reimbursement  for  all  kinds  of  damages,  especially  backed 
up  by  events,  losses  and  sufferings  largely  imaginable  and  un- 
true and  ofttimes  entirely  impossible. 

In  all  cosmetic  surgery  this  branch  is  the  most  dangerous 
from  that  point  of  view  ;  therefore  the  operator  should  take  his 
case  well  in  hand,  proceed  with  an  unshakable  determination 
and  give  the  patient  to  understand  his  position,  even  to  explain- 
ing what  disappointments  there  might  be  and  what  dangers,  if 
any,  he  might  look  forward  to.  The  author  believes  it  no  un- 
just demand  to  have  an  agreement  made  with  the  one  to  be 
treated  in  which  these  matters  are  fully  considered.     Such  an 


H\'DROCARBON  PROTHESES  7 

arrangement  will  save  him  much  worry  and  will  tend  in  the 
majority  of  cases  to  keep  his  patient  satisfied. 

On  the  other  hand,  the  operator  should  not  undertake  to  do 
an  operation  of  a  cosmetic  nature  unless  he  has  a  fundamental 
and  practical  experience  of  long  standing  in  this  branch  of  sur- 
gery and  is  ready  at  all  times  to  cope  with  such  post-opera- 
tive conditions  as  are  likely  to  arise,  which  will  be  described 
later. 

The  author  has  on  various  occasions  been  asked  to  correct 
the  most  hideous  malformations  of  parts  of  the  face,  partic- 
ularly the  nose,  in  which  surgeons  of  high  standing,  both  here 
and  abroad,  had  injected  paraffine  in  liquid  form  usually  under 
a  general  anesthetic,  the  most  remarkable  being  that  of  a  hos- 
pital orderly  in  the  U.  S.  Service,  who  had  been  subjected  to 
not  only  one  of  such  injections  to  correct  a  saddle  nose  under 
chloroform  anesthesia,  but  to  three  distinctive  operations,  with 
the  result  of  a  permanent  disfigurement,  bettered  only  by  a  suc- 
cession of  excisions  at  different  parts  of  the  nose. 

Apropos  of  such  cases  it  may  be  timely  to  state  that  a  gen- 
eral anesthetic  for  the  performance  of  a  prothetic  injection 
operation  is  never  justifiable  and  should  be  considered  a  lack  of 
knowledge  on  the  part  of  the  operator,  unless  its  use  be  advised 
by  another  surgeon  in  consultation. 

The  greatest  mistake  made  with  this  so-called  "  filling 
method  "  has  been  a  desire  on  the  part  of  the  patient  or  the  oper- 
ator, or  both,  to  complete  the  work  too  quickly.  Unscrupulous 
operators  have  restored  a  saddle  nose  or  the  contour  of  the 
cheeks  in  a  few  minutes,  when  it  is  an  established  fact  that  the 
work  should  be  done  slowly,  giving  time  for  the  injections  to 
accommodate  themselves    and  to   organize    before  others  are 


8  HYDROCARBON  PROTHESES 

attempted.  This  is  not  only  true  of  fillings  about  the  cheeks 
and  shoulders,  but  also  of  injections  about  the  nose  and  fore- 
head. 

Eschweiler  ^^  particularly  emphasizes  the  advocacy  of  oft-re- 
peated injections,  and  the  author  recommends  such  rule  without 
reserve  or  deviation. 

THE  ADVANTAGE  OF  THE  METHOD 

As  has  been  said  the  advantage  of  the  Gersuny  method  over 
other  procedures  is  that  it  can  be  undertaken  practically  with- 
out pain,  that  it  is  quick,  bloodless,  leaves  no  scar  and  is  harm- 
less except  under  good  condition,  as  will  be  referred  to  under 
separate  heading. 

While  the  method  entails  only  the  pain  of  a  pin  prick  a  local 
anesthesia  may  be  employed  to  overcome  this,  but  never  a  gen- 
eral anesthetic.  The  Ethyl  Chloride  spray,  except  at  very 
small  points  of  the  skin,  is  not  to  be  recommended  because  it 
freezes  and  consequently  hardens  the  very  tissue  which  should 
be  flexible,  the  operation  being  undertaken  the  moment  the 
needle  is  inserted  and  lasting  only  a  few  seconds.  The  hypo- 
dermic use  of  a  2%  solution  of  cocaine,  or  better  Eucaine  ^,  can 
be  employed,  but  the  author  sees  no  advantage  in  it,  as  the 
hypersemic  engorgement  following  its  use  obliterates,  to  a  cer- 
tain degree,  the  actual  extent  of  the  deformity. 

It  is  desirable  to  obtain  the  best  result  to  have  the  skin  above 
the  part  as  free  as  possible.  When  closely  adherent  it  should 
be  freed  by  the  careful  use  of  a  dehcate  tenotome,  inserted  at 
the  point  where  the  injection  is  to  be  made,  the  same  opening 
being  used  for  the  introduction  of  the  needle  of  the  syringe. 
If  this  opening  has  been  made  too  large  a  fine  suture  of  silk  should 


HYDROCARBON  PROTHESES  9 

be  employed  to  bring  the  lips  of  the  wound  together  before  the 
injection  is  made  ;  the  needle  point,  being  knife-edged,  will  not 
disturb  the  apposition  and  will  tend  to  retain  the  filling  if  no 
undue  pressure  is  used  as  in  the  case  of  hyperinjection. 

UNTOWARD  RESULTS 

Connell  ^^  has  tabulated  the  difficulties  and  dangers  met  with 
in  this  work  as  follows  : 

1.  Toxic  absorption. 

2.  Marked  inflammatory  reaction. 

3.  Loss  of  tissue,  due  to  infection  and  abscess  formation. 

4.  Pressure  necrosis,  caused  by  hyperinjection. 

5.  Sloughing  of  tissue  as  a  result  of  the  heat  of  paraffine. 
9.  Injection  into  very  dense  or  inelastic  structures,  or  where 

scar  tissue  is  firmly  attached  to  the  underlying  and 
adjacent  parts. 

7.  Sub-injection  of  too  small  an  amount  of  paraffine  with  an 

insufficient  correction  of  the  deformity. 

8.  Hyperinjection  with  over-correction  of  deformity. 

9.  Air  embolism. 

10.  Paraffine  embolism. 

1 1.  Primary  diffusion  or  extension  of  paraffine  (when  first  in- 

troduced) into  adjacent  normal  structures, 

12.  Interference  with  muscular  action  of  the  nose. 

13.  Escape  of  paraffine  after  the  withdrawal  of  the  needle  or 

primary  elimination. 

14.  Solidification  of  the  paraffine  in  the  needle,  which  renders 

the  injection  difficult  and  causes  injudicious  expedition 
on  the  part  of  the  operator. 

15.  Absorption  or  disintegration  of  the  paraffine. 


lo  HYDROCARBON  PROTHESES 

1 6.  The  difficulty  of  procuring  paraffine  at  the  proper  melt- 

ing point. 

17.  Hypersensitiveness  of  the  skin  over  the  injected  area. 

18.  Redness  of  the  skin  over  the  injected  area. 
To  those  the  author  would  add  : 

19.  Secondary  diffusion  of  the  injected  mass. 

20.  Hyperplasia  of  the  connective  tissue  following  the  organ- 

ization of  the  injected  matter. 

21.  A  yellow  appearance  and  thickening  of  the  skin  after  or- 

ganization of  the  injected  mass. 

22.  The  breaking  down  of  tissue  and  the  resulting  abscess 

due  to  the  pressure  of  the  injected  mass  upon  the  ad- 
jacent tissue  after  the  injection  has  become  organized. 

Each  of  the  above  subdivisions  may  be  advantageously  con- 
sidered individually,  to  wit : 

I.  Intoxication. — The  danger  of  intoxication  may  truly  be  said 
to  be  more  so  due  to  the  unclean  or  unsterilized  matter  injected 
than  to  the  absorption  following  its  employment,  although 
Meyer  ^^  has  claimed  untoward  symptoms  found  in  his  experi- 
ments from  absorption  of  injections  of  vaseline  in  the  animal. 
Taddie  and  Delain,^^  Stubenrath,^^  Straume,^'*  Sobieranski  ^' 
and  Dunbar  ^^  have  corroborated  this  claim.  They  injected 
paraffine  of  various  melting  points  in  the  lower  animals  and  ob- 
served results  therefrom,  among  which  were  loss  of  hair,  a  re- 
duction of   I  S%  in  the  body  weight  in  two  months  and  death. 

Stein  ^'  and  Harmon  Smith  ^*  refute  these  conditions  and 
remarked  neither  systemic  nor  local  untoward  results  from 
such  injections  when  paraffine  of  higher  melting  points  were 
used. 

Jukuff  ^^  claims  that  no  toxic  symptoms  result  from  the  ab- 


HYDROCARBON  PROTHESES  ii 

sorption  of  paraffine  injected  into  tissues  are  shown,  unless  the 
amount  be  equal  to  lo^  of  the  weight  of  the  animal.  To  have 
this  apply  to  the  human  as  much  as  ten  to  fifteen  pounds  would 
have  to  be  injected — an  amount  never  required  in  operations 
of  this  nature. 

While  it  cannot  be  denied  that  the  injected  mass  becomes 
more  or  less  absorbed  in  from  two  to  three  months  and  is  re- 
placed by  connective  tissue,  it  may  be  definitely  stated  that  no 
toxic  symptoms  are  caused  directly  thereby,  except  by  the  em- 
ployment of  an  impure  product. 

2.  Reaction, — The  reaction  following  a  properly  made  injec- 
tion is  of  a  mild  inflammatory  character.  Considerable  inflam- 
mation points  to  some  fault  in  the  technique  or  impurity  of  the 
injection.  More  or  less  oedema  of  the  site  and  its  adjacent  area 
may  be  noted,  associated  with  slight  or  marked  discoloration 
and  pain  of  variable  degree.  The  normal  reaction  following  the 
injection  is  temporary  and  does  not  necessitate  treatment  or 
confinement  of  the  patient,  who  can  resume  the  duties  of  life 
fifteen  hours  after  the  operation. 

3.  Infection. — The  cause  of  infection  cannot  be  said  to  be  due 
to  anything  but  surgical  uncleanliness,  as  it  is  with  any  surgical 
undertaking,  and  can  be  overcome  by  the  same  means. 

The  material  injected  should  be  thoroughly  sterilized  by  boil- 
ing before  using.  Broeckaert '"'  suggests  combining  an  antisep- 
tic with  the  paraffine  and  has  used  guiaform,  a  combination  of 
formic  aldehyde  and  guiacol  in  a  proportion  of  5  to  10%  ;  yet 
this  is  of  little  value  when  we  consider  how  readily  these  hydro- 
carbons can  be  rendered  sterile  at  high  temperatures, 

4.  Necrosis, — Death  of  tissue  may  follow  an  injection  of  paraf- 
fine when   too  much  pressure  has  been  applied,  or  when  too 


12  HYDROCARBON  PROTHESES 

much  has  been  injected  into  the  tissue,  cutting  off  the  blood 
supply,  or  when  the  injection  has  been  made  into  the  skin  in- 
stead of  beneath  it.  Again,  constitutional  disease,  such  as  dia- 
betes or  Bright's  disease,  may  superinduce  the  breaking  down 
of  the  tissue. 

Hyperinjection  should  and  can  be  avoided  by  the  use  of  the 
proper  instrument  with  which  the  required  amount  is  graduated 
to  a  nicety.  At  no  time  should  an  injection  be  crowded  into  a 
dense  tissue  or  where  the  skin  is  closely  adherent,  nor  carried 
so  far  as  to  create  a  blanching  of  the  skin.  By  carefully  inject- 
ing the  mass  this  danger  should  be  overcome. 

Dense  or  bound-down  areas  of  skin  should  be  loosened  and 
freed,  as  has  already  been  mentioned. 

If  care  be  exercised  and  small  amounts  be  injected,  in  prefer- 
ence to  overcoming  the  defect  in  one  sitting,  pressure  effects  are 
entirely  overcome. 

The  circulation  in  the  skin  over  the  site  of  injection  should 
be  normal  immediately  after  the  operation  has  been  performed, 
determined  by  observing  the  reaction  in  the  color  of  the  skin 
after  delicate  digital  pressure. 

5.  Sloughing. — That  sloughing  of  the  skin  should  be  oc- 
casioned by  the  high  temperature  of  the  paraffine  injected  is  a 
condition  entirely  inexcusable.  Paraffine  of  high  melting  points 
58°  to  65°  C,  or  the  so-called  "Hart  paraffine"  employed  by 
Wolff,  ^^  liquefying  at  from  5  7°  to  60°  C,  are  to  be  used  with, 
caution.  The  author  doubts  whether  the  temperature  of  the 
paraffine  at  the  time  of  injection,  even  in  the  latter  method,  is 
ever  beyond  54°  C.  even  if  the  thermometer  registers  60°  C.  in 
the  liquefying,  hot  water  bath. 

By  the  time  it  has  been  drawn  into  the  syringe,  which  has 


HYDROCARBON  PROTHESES  13 

been  heated  by  dipping  into  hot  water,  and  the  moment  it  is  in- 
jected it  has  lost  several  degrees  in  heat. 

It  would  not  be  permissible  to  inject  a  molten  mass  of  a  tem- 
perature so  high  as  to  scar  or  burn  the  tissues,  and  the  best  re- 
sults of  most  operators  have  been  obtained  with  such  of  the  par- 
affine  group  that  become  liquified  at  a  temperature  of  not  over 
45°  C.  (112°  F.). 

The  claim  of  Eckstein,  '^^  that  paraffines  of  low  melting  points 
are  more  likely  to  be  absorbed,  has  not  been  substantiated  in  act- 
ual practice,  since  we  now  know  that  any  and  all  of  these  injections 
irrespective  of  their  melting  points,  are  absorbed  in  time,  giving 
place  to  connective  tissue,  and  that  rarely,  if  ever,  is  there  a 
true  and  complete  encapsulation  or  encystment  of  the  mass  thus 
introduced.  Even  the  hard  paraffines  are  spHt  up  in  time  into 
minute  pearl-like  particles  which  are  displaced  by  the  growth  of 
tissue  arising  from  the  presence  of  the  foreign  substance.  This 
is  true  even  in  those  cases  in  which  the  author  has  introduced 
by  surgical  means  solid  paraffine  plates  in  the  cold  state. 

6.  Sloughing  Due  to  Pressure. — When  an  injection  is  forced 
into  a  dense  or  firmly  bound-down  tissue,  as  into  the  body  of  a 
thickened  cicatrix,  or  about  the  point  of  the  nose  or  the  sub- 
septum  of  the  nose  without  first  dissecting  off  the  skin  above 
the  subcutaneous  layers  an  acute  anaemia  is  at  once  marked, 
followed  by  inflammation  and  gangrene. 

By  injecting  sterile  water  into  the  area  thus  loosened  with  the 
knife  a  good  idea  of  the  thoroughness  of  the  dissection  and  the 
possibility  of  building  up  the  part  to  be  corrected,  is  obtained, 
yet  in  these  cases  the  author  has  always  found  more  or  less 
difficulty  in  keeping  the  injected  mass  in  place  for  the  reason 
that  the  divided  surfaces  tend  to  unite  at  their  peripheral  bor- 


14  HYDROCARBON  PROTHESES 

ders,  crowding  the  mass  upward  or  to  one  side  or  diffusing  it  in 
such  a  way  that  the  result  has  been  anything  but  satisfactory. 

To  overcome  this  it  is  advisable  to  inject  a  smaller  quantity 
than  necessary  to  entirely  correct  the  defect,  to  mould  it  out 
flat  and  to  allow  it  to  organize^  before  more  is  introduced. 

7.  Subinjection. — Insufficient  injection  leading  to  an  under- 
correction  of  the  defect  is  a  far  more  desirable  condition  than 
hyperinjection  and  is  easily  corrected  by  a  repetition  of  the 
treatment,  even  to  a  third  sitting,  until  the  desired  result  is  ob- 
tained. Following  this  rule  will  give  far  better  results,  as  has 
been  said,  than  to  be  compelled  to  remove  a  part  of  the  filling 
and  some  of  the  connective  tissue  which  has  resulted  there- 
from. 

8.  Hyperinjection. — The  injection  of  too  much  vasehne  or 
paraffine  is  one  of  the  most  common  faults  found  with  operators. 
In  the  first  instance  a  tumefaction  of  the  site  results  which  with 
the  production  of  the  tissue  which  takes  the  place  of  part  of  the 
filling  makes  the  result  very  unsatisfactory  and  requires  one  or 
more  cutting  operations  to  reduce  it.  A  peculiar  fact  with  these 
hyperplastic  growths  is  that  even  though  they  may  be  reduced 
with  the  knife  to  a  normal  size  they  seem  to  redevelop  again 
and  again,  giving  both  surgeon  and  patient  great  concern. 

This  in  the  opinion  of  the  author  is  due  to  the  binding  down 
of  the  marginal  borders,  which  in  the  event  of  partial  extirpa- 
tion, are  not  injured  sufficiently  to  displace  them  and  that  they 
unite  again  in  their  former  position.  To  overcome  this  it  is 
found  best  to  excise  the  entire  filling  much  beyond  the  margins 
and  to  apply  pressure  over  the  area  until  perfect  union  has  taken 
place. 

This  is  best  accomplished  with  a  disc  of  aluminium,  bent  to 


m'DROCARBON  PROTHESES  15 

conform  to  the  shape  of  the  part  operated,  lined  with  sterilized 
lint  and  fixed  over  the  site  by  strips  of  Z.  O.  plaster. 

While  the  hyperinjection  of  vaseline  is  not  as  objectionable 
as  that  of  paraffine,  because  of  the  more  ready  accommodation 
and  absorption  of  the  mass,  it  nevertheless  leads  to  diffusion  of 
the  material  owing  to  its  softer  consistency  and  consequent 
greater  facility  in  seeking  fine  avenues  of  escape,  paraffine  hav- 
ing the  advantage  of  cooling  upon  itself  en  masse,  leaving  little 
to  escape  into  undesirable  channels  after  it  has  once  been  moulded 
and  set. 

Vasserman  ■^^  cites  a  case  in  which  gangrene  of  the  bridge  of 
the  nose  resulted  after  an  injection  of  2^  c.  c.  of  vasehne. 

However,  when  these  faults  occur  they  are  errors  of  technique 
and  should  be  avoided  as  has  been  mentioned  heretofore. 

The  removal  of  such  hyperinjected  masses  by  the  aid  of  par- 
affine solvents,  such  as  benzine,  ether,  chloroform  or  xycol  applied 
to  the  skin  above  the  filling  has  proved  a  failure,  nor  will  heat 
used  externally  in  the  same  manner  remedy  evil. 

What  is  left  to  the  operator  is  to  open  the  skin  and,  with  a 
small,  sharp  spoon  curette,  remove  the  mass  early,  before  it  has 
become  organized,  or  to  excise  the  new  connective  tissue  and 
the  broken-down  filling  as  mentioned. 

When,  however,  the  tumefaction  resulting  from  such  hyperin- 
jection is  not  extensive,  as  is  often  found  about  the  chin  and  at 
the  root  of  the  nose,  the  secondary  deformity  can  be  materially, 
if  not  entirely,  remedied  by  electrolysis.  A  needle  or  brooch 
of  certain  hardness  is  to  be  employed,  connected  with  the  nega- 
tive pole  of  a  continuous  current  apparatus.  From  twelve  to 
twenty  milliamperes  are  required.  The  process  is  similar  to  that 
used  with  the  destruction  of  hair,  nsevi  or  moles  on  the  face. 


i6  HYDROCARBON  PROTHESES 

The  needle  should  puncture  the  entire  tumor  or  penetrate  its 
maximum  diameter  and  be  charged  with  the  current  for  two  or 
three  minutes.  Several  of  such  punctures  should  be  made  at 
each  sitting,  the  latter  being  repeated  as  often  as  is  deemed  nec- 
essary by  the  operator.  The  reaction  which  follows  this  pro- 
cedure is  of  little  moment  and  these  sittings  can  be  undertaken 
every  three  or  four  days. 

While  this  method  is  liable  to  leave  little  punctuate  scars  at 
the  sites  where  the  needle  is  introduced,  it  is  nevertheless  more 
satisfactory  than  the  linear  scar  made  with  the  knife  to  the  use 
of  which  the  patient  may  on  the  other  hand  object,  not  to  speak 
of  the  difficulty  and  unsatisfactory  results  usually  obtained 
therewith. 

9.  Air  Embolism. — The  fault  of  introducing  air  under  the  skin 
with  the  syringe  at  the  time  of  injection  can  only  be  the  result 
of  flagrant  negligence.  Every  physician  should  know  enough 
to  hold  his  syringe  in  an  erect  or  vertical  position  and  to  expel 
the  air  above  the  solution  in  his  syringe,  as  is  done  with  any  hy- 
perdermic  injection. 

Air  embolisms  are  also  occasioned  by  a  careless  filling  of  the 
syringe  with  the  hydrocarbon  in  a  cold  state,  as  the  material  is 
now  generally  used,  and  while  the  dangers  of  such  emboli  are 
very  much  exaggerated  they  should  not  be  permitted,  when  by 
the  pouring  in  of  the  liquefied  material  the  syringe  can  be  filled 
evenly. 

Practically  there  is  no  harm  done  by  the  injection  of  air  un- 
der the  skin,  yet  it  elevates  the  skin  at  the  site  of  the  defect 
and  hinders  the  surgeon  in  accompHshing  the  best  results. 

These  emboh  cause  a  bulging  up  of  the  skin  for  the  time  being 
and  may  occasion  more  or  less  pain  to  the  patient,  which  passes 


HYDROCARBON  PROTHESES  17 

away  in  ten  or  twelve  hours  leaving  the  parts  as  injected  except 
for  such  reactionary  symptoms  or  oedema  already  referred   to. 

ID.  ParaflSne  Embolism. — The  creation  of  an  embolism  is  in- 
variably due  to  an  injection  of  the  foreign  substance  directly 
into  a  blood  vessel.  This  condition  is  one  of  the  most  objec- 
tionable, if  not  the  most  dangerous  factor  associated  with  the 
subcutaneous  injection  of  any  foreign  matter,  be  it  a  liquid  sub- 
stance, as,  for  instance,  an  oil ;  many  cases  have  been  placed  on 
record  where  they  have  been  observed  after  the  introduction  of 
even  paraffine  of  high  melting  points,  when  introduced  under 
the  skin  in  hot  liquid  state.  Consequently  the  use  of  vaseline 
liquefied  by  the  aid  of  heat  is  especially  liable  to  give  rise  to  such 
condition, 

Pfannenstiel  •*"*  cites  a  case  wherein  he  injected  paraffine  in 
which  the  patient  was  at  once  attacked  with  violent  coughing 
and  for  three  days  exhibited  symptoms  of  grave  nature,  such  as 
pain  in  side,  intense  dyspnoea,  acceleration  of  the  pulse,  hyper- 
thermia, cyanosis  of  the  face,  hemoptysis,  violent  cephalalgia  and 
vomiting — all  indications  of  pulmonary  and  cerebral  embolism. 
The  injection  in  this  case  was  one  of  30  c,  c,  of  paraffine,  with 
a  melting  point  of  4^°  C,  The  symptoms  as  mentioned  con- 
tinued for  about  one  week,  gradually  subsiding  and  followed  by 
recovery, 

Kapsammer  ^^  has  also  noticed  such  symptoms,  Leiser  ^^ 
after  injecting  vaseline  to  correct  a  saddle  nose  noted  an  im- 
mediate collapse  of  the  patient  which  was  obviated  only  by  the 
hypodermic  use  of  ether  and  the  resort  to  artificial  respiration. 
When  the  patient  returned  to  consciousness,  he  was  found  to 
be  entirely  blind  in  the  right  eye,  the  eye  before  the  operation 
having  been  known  to  show  only  a  pronounced  astigmatism. 


i8  HYDROCARBON  PROTHESES 

Kofman  "^^  cites  the  loss  of  a  patient  from  the  injection  of 
lo  C.C,  of  paraffine  for  vaginal  prolapsis.  Moskowicz^®  ob- 
served two  cases  of  pulmonary  embolism  treated  in  the  same 
manner  stating  that  an  alarming  dyspnoea  continued  for  several 
hours. 

Especially  have  cases  in  which  the  injections  of  paraffine  were 
made  sub-mucously  for  the  correction  of  atrophic  coryza  shown 
embolic  tendencies.  This  is  especially  true  when  paraffines  of 
high  melting  points  have  been  employed,  as  in  the  case  of. 
Pfannenstiel  in  which  instance  the  condition  of  the  mass  per- 
mitted of  freer  absorption  or  the  high  temperature  caused  a 
coagulation  of  the  blood  in  the  veins,  leading  to  thrombosis  and 
embolism,  and  when  the  amount  of  such  an  injection  is  so  large 
as  to  prevent  cooling  and  hardening  in  the  normal  space  of  time 
added  to  the  quantity  and  associated  at  the  same  time  with  con- 
sequent pressure,  predisposing  to  absorption  or  dissemination, 
especially  if  the  injection  be  made  into  parenchymatous  instead 
of  the  subcutaneous  tissue. 

Comstock^^  in  his  experience  on  animals,  states  that,  "in  all 
cases  in  which  paraffine  was  used  at  102°  F.  the  animals  died 
within  two  weeks'  time,  hence  the  specimens  at  that  tempera- 
ture are  hmited  (death  being  by  thrombosis).  In  all  other 
cases  with  the  higher  melting  point  i  io°F.  no  unpleasant  results 
were  experienced." 

Hurd  and  Holden  ^°  have  observed  a  patient  who  had  previ- 
ously undergone  two  injections  of  paraffine  for  the  correction  of 
a  depression  in  the  upper  part  of  the  nose.  A  third  injection 
was  advised  and  made  under  the  same  conditions  as  the  first, 
except  that  no  cocaine  anesthesia  was  employed,  the  paraffine 
being  at  the  same  temperature  as  before. 


HYDROCARBON  PROTHESES  19 

The  moment  the  injection  was  made  complete  blindness  in 
the  right  eye  resulted,  while  a  small  ecchymotic  spot  appeared 
at  the  site  of  the  needle  insertion  in  the  skin.  Half  an  hour 
later  an  examination  of  the  eye  showed  the  right  pupil  dilated 
and  inactive  light  stimulus,  the  patient  being  unable  to  distin- 
guish light  from  darkness.  Opthalmoscopically  the  lower  branch 
of  the  central  retinal  artery  and  its  subdivisions  were  found  to 
empty  and  in  a  state  of  collapse,  evidenced  by  their  pale  ap- 
pearance. The  upper  branch  of  the  same  vessel  was  found  to 
be  poorly  filled. 

The  authors  endeavored  to  remove  the  embolism  to  a  collat- 
eral branch  of  the  artery  by  the  use  of  amyl  nitrate,  digitalis 
and  pressure  on  the  globe  of  the  eye,  with  no  effect.  Some 
hours  later  oedema  of  the  retina  appeared,  followed  by  perma- 
nent loss  of  sight.  The  same  authors  have  observed  several 
cases  of  pulmonary  embolism  result  from  the  injection  of  par- 
affine. 

It  is  also  a  fact  that  injections  of  the  nature  being  considered 
while  not  causing  immediate  embolism  may  do  so  as  a  result  of 
phlebitis  caused  by  a  direct  injection  into  the  vein  or  over  or 
upon  it  in  such  a  way  as  to  cause  irritation. 

Mintz  ^^  reports  a  third  case  of  amaurosis  following  a  paraf- 
fine  injection.  The  latter  was  made  to  correct  a  saddle  deform- 
ity caused  by  syphiHs.  Three  minutes  after  the  injection  the 
patient  complained  of  pain  in  the  left  eye  which  was  followed  by 
total  blindness,  vomiting  and  a  pulse  of  forty-eight.  Several 
days  later  there  appeared  symptoms  of  venous  congestion  in  the 
orbit,  paralysis  of  the  ocular  muscles,  comeal  cloudiness  and  ex- 
aphthalmos  a  small  grangrenous  spot  appeared  at  the  site  of  the 
injection. 


20  HYDROCARBON  PROTHESES 

Broeckaert  ^^  observed  a  case  of  facial  phlebitis,  followed  by 
pulmonary  infarction.  Brindel  ^^  cites  a  case  in  which  he  ob- 
served a  hard  line  of  considerable  extent  and  painful  to  the 
touch,  extending  from  the  inner  angle  of  the  eye  to  the  angle 
of  the  eye,  where  it  deviated  towards  the  root  of  the  nose  and 
terminated  at  the  origin  of  the  eyebrow. 

De  Cazeneuve  ^"*  made  an  injection  and  on  the  following  day 
noted  that  the  right  cheek  had  increased  considerably  in  size 
with  an  elevation  of  temperature  in  the  part.  Two  days  after 
under  the  right  eye  and  to  the  right  of  the  nose  the  whole  cheek 
was  red,  hot  and  much  distended,  giving  the  skin  a  glazed  ap- 
pearance. Palpation  was  extremely  painful.  A  hard  line  could 
be  made  out  extending  from  the  inner  angle  of  the  eye  outward 
and  downward  under  the  lower  eyelid  and  terminating  in  the 
center  of  the  oedematous  cheek.  The  phlebitis  in  this  case  re- 
sulted without  the  development  of  an  embolism. 

After  a  careful  study  of  the  causes  of  such  embolisms  we 
come  to  the  conclusion. 

1.  That  the  injected  mass  should  not  be  heated  above  a  cer- 
tain melting  point. 

2.  That  hyperinjection  should  at  all  times  be  avoided,  partic- 
larly  with  paraffines  of  high  melting  points. 

3.  That  the  injection  should  be  made  subcutaneously  not  into 
parenchymatous  tissues,  and 

4.  That  a  puncture  of  a  vein  or  the  introduction  of  the  in- 
jected mass  into  a  vein  should  be  avoided. 

In  the  consideration  of  the  first  two  causes  the  author  advocates 
using  injections  of  low  melting  points  only  at  all  times,  in  fact 
from  his  experience  with  over  two  thousand  subcutaneous  in- 
jections he  relies  entirely  upon  such  paraffines  or  hydrocarbon 


HYDROCARBON  PROTHESES  21 

mixtures  as  are  semisolid  at  70°  F.  appearing  as  a  white  cylin- 
drical thread  from  the  needle  of  the  syringe  as  pressure  is  ap- 
plied. 

With  such  a  preparation  and  a  careful  introduction  of  the 
needle  as  described  later  and  with  the  injection  of  an  amount 
much  less  than  that  needed  to  correct  the  deformity  and  proper 
digital  compression  on  the  blood  vessels  and  about  the  site  of 
the  injection  embolism  is  practically  impossible. 

The  avoidance  in  the  third  instance  is  self-evident  and  it  is 
to  the  fourth  fault  and  cause  that  we  must  pay  particular  atten- 
tion. 

Stein  ^^  says  that  all  that  is  necessary  to  avoid  puncturing  a 
vein  is  to  first  introduce  the  needle  alone  under  the  skin  and  to 
attach  the  syringe  only  when  it  is  found  no  flow  of  blood  re- 
sults from  the  puncture  thus  made. 

Freeman  ^^  and  the  author  add  to  this  by  advocating  the  use 
of  a  somewhat  blunt  pointed  needle  instead  of  the  extremely 
sharply  pointed  knife-edged  needles  usually  furnished  with 
syringes  intended  for  this  purpose. 

II.  Primary  Diffusion  or  Extension  of  Parafiine. — The  spread- 
ing of  parafifine  into  normal  tissues  about  the  site  to  be  corrected 
by  prothetic  injection  is  a  fault  due  principally  to  a  careless  use 
of  the  syringe.  The  employments  of  an  improper  syringe  in 
in  which  the  amount  to  be  injected  cannot  be  graduated  or  con- 
trolled will  be  considered  later — the  result  with  such  being  hy- 
perinjection.  In  this  event  when  the  anterior  line  of  the  nose 
is  to  be  restored,  the  mass  is  liable  to  find  its  way  into  the  loose 
areolar  tissue  of  the  infraorbital  region  ;  in  correcting  a  nasola- 
bial furrow  the  mass  is  pushed  upward  or  is  forced  into  the  tissue 
of  the  cheek  above  it  aggravating  the  trouble ;  in  obliterating  a 


22  HYDROCARBON  PROTHESES 

frown  it  travels  upward  toward  the  margin  of  the  scalp  giving  a 
median  prominence  to  the  forehead  that  is  found  to  be  very  dif- 
ficult to  correct ;  in  injections  about  the  mouth  the  mass  moves 
down  upon  the  chin  or  accumulates  at  the  angle  of  the  jaw ;  in 
correcting  the  creases  beneath  the  chin  it  seeks  the  sides  of  the 
neck,  even  travelling  to  the  superior  border  of  the  clavicle  at  its 
sternal  third.  Many  other  forms  of  such  diffusions  can  be 
mentioned  directly  due  to' primary  diffusion  the  result  of  hyper- 
injection. 

Enough  has  been  said  of  the  danger  of  hyperinjection,  yet 
even  with  a  proper  amount  of  the  injected  mass  this  distention 
may  by  observed.  To  avoid  this  the  operator,  or  his  assistant, 
should  compress  the  margins  of  the  site  of  the  injection  with 
his  fingers  firmly  applied,  as  for  instance  in  the  injection  of  the 
root  of  the  nose  pressure  should  be  made  at  both  inner  canthi 
and  over  the  tissue  just  above  the  root  of  the  nose  and  beneath 
the  finger  tips. 

Downie  ^^  advocates  the  use  of  celloidin  in  the  correction  of  a 
saddle  nose  as  follows  :  He  paints  a  band  of  celloidin  or  colo- 
dion  down  each  side  of  the  nose  limited  by  the  line  of  junction 
with  the  cheeks  and  another  band  across  the  root  of  the  nose. 
These  painted  on  bands  he  allows  to  dry  and  contract  for  fif- 
teen minutes  before  undertaking  the  injection. 

The  contraction  of  these  bands,  prevents  to  a  certain  extent 
the  spreading  or  extension  of  the  liquid  parafiine  into  the  celu- 
lar  tissue  about  the  eyes,  yet  experienced  digital  pressure  is  at 
all  times  to  be  preferred. 

If  a  liquid  paraffine  or  hydrocarbon  mixture  or  vaseline  is 
used,  the  immediate  use  of  ice  cloths  applied  to  the  part  as  dig- 
ital pressure  is  removed,  is  advisable  to  aid  in  the  rapid  bar- 


HYDROCARBON  PROTHESES  23 

dening  or  setting  of  the  injected  mass  before  the  tension  of  the 
tissues  over  and  about  it,  might  influence  it.  With  semisolid 
injection  this  is  not  necessary,  except  in  the  subsequent  treat- 
ment as  will  be  considered  later  because  the  mass,  unless  of  too 
soft  a  consistency,  as  for  instance  vaseline  will  practically  re- 
main as  injected  and  moulded. 

Vaseline  when  injected  into  tissue  where  there  is  tension  would 
naturally  be  forced  out  of  position  and  shape  and  should  not  be 
used  except  in  combination  with  a  paraffine  of  a  melting  power 
high  enough  to  give  the  proper  consistency  to  the  former. 

12.  Interference  with  Muscular  Action  of  the  Wings  of  the  Nose, 
— That  nasal  respiration  may  be  encroached  upon  as  a  result  of 
injecting  paraffine  about  the  nose  has  been  observed  by  Alter.^* 
He  points  out  that  during  nasal  inspiration  there  is  a  tendency 
for  the  alae  to  contract  upon  themselves  or  to  move  inward  de- 
creasing the  lumen  of  the  orifice  and  that  in  the  normal  state 
this  movement  is  counteracted  by  the  action  of  dilator  muscles 
of  the  alae,  that  is  the  dilator  naris  anterioris,  the  pyramidelis 
nasi  and  the  levator  labii  superioris  alaeque  nasi  and  that  this 
muscular  action  is  interfered  with  owing  to  the  pressure  of  the 
paraffine  upon  these  delicate  structures  and  resulting  in  more  or 
less  permanent  collapse  or  indrawing  of  the  alae  during  inspira- 
tion. He  observed  considerable  interference  with  inspiration  in 
a  case  cited  in  which  an  injection  of  paraffine  had  been  made. 

To  avoid  undue  pressure  upon  the  structures  referred  to  it  is 
advised  to  have  an  assistant  place  a  thumb  into  each  nostril  and 
the  index  fingers  without  and  above  the  alae  in  such  way  that 
the  tips  of  the  fingers  may  be  enabled  to  exert  the  necessary 
pressure  over  the  injected  mass  into  these  structures,  and  to 
maintain  this  pressure  until  the  mass  has  been  properly  moulded 


24  HYDROCARBON  PROTHESES 

and  set.  Connell  ^^  advises  inserting  the  little  fingers  into  the 
nostril  to  prevent  an  encroachment  on  the  lumen  of  the  nasal 
canal. 

The  above  applies  particularly  to  those  cases  where  injections 
are  made  into  the  anterior  lower  or  lateral  third  of  the  nose,  as 
for  instance  in  overcoming  slight  depressions  in  the  anterior 
line,  immediately  above  the  lobule  or  in  a  low  unilateral  deviation 
of  the  nose. 

13.  Escape  of  ParaflSne  after  Withdrawal  of  Needle. — When 
the  injected  mass  employed  is  of  a  semisolid  consistency  as 
heretofore  advised,  it  is  hardly  possible  for  the  mass  to  be  forced 
out  through  the  opening  of  the  skin  made  by  the  introduction 
and  withdrawal  of  the  needle,  unless  there  be  an  unwarrantable 
immobility  of  the  skin  above  the  site  to  be  injected.  The  latter 
should  be  corrected  before  injection. 

The  mass  after  having  been  moulded  in  the  shape  desired 
may  be  further  hardened  and  set  by  the  application  of  ice  cloths 
or  spraying  with  ether  before  the  needle  is  withdrawn  from  the 
skin,  yet  this  is  hardly  necessary  and  the  author  advises  against 
the  practice  for  the  reason  that  pressure  of  the  needle  prevents 
proper  and  free  moulding  of  the  mass  and  renders  the  tissue 
liable  to  further  injury  by  scraping  its  point  to  and  fro  subcu- 
taneously  adding  to  the  extent  of  the  wound  and  the  dangers 
of  infection  and  repair. 

The  skin  immediately  around  the  needle  hole,  after  with- 
drawal of  the  needle,  may  be  gently  smoothed  out  with  the  dull 
rounded  metal  handle  end  of  the  bistoury  to  free  the  inter- 
dermal  canal  of  any  foreign  matter. 

The  skin  about  the  needle  hole  is  then  gently  washed  with  a 
$0%  solution  of  hydrogen  peroxide,  dried  with  a  sterile  cotton 


HYDROCARBON  PROTHESES  25 

sponge  and  the  opening  sealed  with  a  drop  of  collodion.  Sub- 
sequent treatment  of  the  parts  will  be  considered  later. 

14.  Solidification  of  Paraflfine  in  Needle. — This  occurs  only 
when  parafifines  of  high  melting  points  are  employed  in  liquid 
form  in  the  syringe,  and  is  due  to  the  rapid  cooUng  of  the  par- 
affine  in  the  small  metallic  canulae,  or  needle,  wherein  it  sets 
more  readily  since  the  volume  contained  therein  is  very  small, 
often  not  more  than  two  or  three  drops. 

This  cooling  establishes  a  plug-like  formation  in  the  distal  end 
of  the  needle  which  prevents  a  proper  use  of  the  syringe,  often 
breakage,  and  when  suddenly  liberated  by  an  extra  pressure  on 
the  piston  rod  causes  a  rapid  discharge  of  the  contents  of  the 
syringe  to  an  extent  not  desired  with  the  result  of  hyperinjection. 

This  fault  was  one  of  the  most  annoying  in  the  early  days  of 
such  injections  when  syringes  of  ordinary  pattern,  such  as  the 
Pravaz,  or  those  built  like  the  ordinary  hypodermic  were  used. 
It  was  not  unusual  to  have  the  parafifine  cool  in  the  needle  so 
quickly  between  the  latter  in  the  flame  of  an  alcohol  lamp,  that 
the  syringe  became  unmanageable  and  broke  in  the  hands  of 
the  operator.  Since  that  time  new  and  more  useful  syringes 
have  been  introduced  by  various  operators  which  overcome  this 
difficulty,  yet  with  them,  too,  come  the  employment  of  semi- 
solid paraffines  or  mixtures  thereof.  Yet  as  some  authors  in- 
sist upon  using  paraffines  of  high  melting  points  it  may  be  well 
to  rehearse  their  methods  of  overcoming  this  annoying  intra- 
needle  solidification. 

Eckstein  ^"  surrounds  the  syringe  and  needle  shaft,  except  the 
tip  of  the  needle,  with  a  rubber  tubing  as  shown  in  Fig.  I, 
to  act  as  an  insulator  and  thus,  for  a  time  at  least,  keep  the 
preparation  liquid.     Before  filling  the  syringe  he  heats  it  by  sev- 


26 


HYDROCARBON  PROTHESES 


eral  immersions  in  and  internal  washings  of  hot  sterile  water. 
To  prevent  the  paraffine  from  setting  in  the  exposed  tip  of  the 
needle  he  draws  into  the  filled  syringe  a  few  drops  of  hot  water 
which^are  injected  into  the  tissues,  causing  no  objection  to  the 
method. 

Paget  ^^  and  Harmon  Smith  ^^  warm  the  needle  in  hot  steril- 
ized or  even  boiling  water.     Previous  to  this  Smith  cools  the 


Fig.  I.     Eckstein's  Insulating  Sleeve. 


contents  of  the  syringe  drawn  into  it  at  a  temperature  of  120°  F. 
by  immersing  the  latter  in  a  bath  of  sterilized  water  at  a  tem- 
perature of  80°  F. 

From  the  above  it  will  be  noted  that  Smith  advocates  using 
the  injections  in  semisolid  state  being  ejected  in  a  thin,  cylin- 
drical thread.  A  syringe  of  special  construction  as  referred  to 
laser  is  of  course  required  for  such  work. 

Quinlan  ^^  has  invented  a  so-called  paraffine  heater  as  shown 
in  Fig.  II,  in  which  the  paraffine  is  kept  in  solution  by  the 
syringe  being  surrounded  by  a  continuous  flow  of  hot  water.  A 
plain  and  very  objectionable  syringe  is  shown  in  the  illustration 
and  while  the  preparation  in  the  syringe  is  thus  kept  in  a  hquid 
state  the  solidification  in  the  needle  is  not  overcome. 

Downie  ^^  winds  fine  platinum  wire  about  the  needle  through 


HYDROCARBON  PROTHESES 


27 


which  he  passes  the  current  from  a  storage  battery  to  keep  the 
needle  hot  yet  such  an  arrangement  is  obviously  difficult  of 
manipulation  and  when  paraffines  of  high  melting  points  are  em- 
ployed it  is  quite  likely  that  a  plug  is 
formed  in  the  exposed  point  of  the 
needle. 

Karewski  ^^  has  introduced  a  syringe 
having  a  jacket  through  which  hot 
water  is  allowed  to  circulate,  while  sim- 
ilar instruments  have  been  originated 
by  Pflugh  ^^  and  DeCazeneuve.^^  None 
of  these  overcome  the  difficulty  in 
question. 

Viollet  ^^  went  even  further  by  invent- 
ing a  syringe  surrounded  with  a  coil  of 
resistance  wire,  heated  by  an  electrical 
current,  and  Delangre,^^  Ewald^*^  and 
Moszkowicz  ^^  use  special  thermophorm 
sleeves  over  the  syringe  proper,  all  how- 
ever offering  the  same  objection  in  the 
exposure  of  a  part  of  the  needle  in 
which  temperature  of  the  Hquid  must 
necessarily  be  lowered,  or  be  low  enough 
to  cause  plugging,  the  very  fault  for 
which  all  these  modifications  have  in- 
cidentally been  urged,  as  the  greater 
amount  of  paraffine  in  the  syringe  itself  is  as  a  rule  large  enough 
to  retain  sufficient  heat  to  permit  of  its  ejection,  if  the  in- 
jection is  made  as  expeditiously  as  possible. 

The  objection  of  the  setting  of  the  paraffine  in  the  barrel  of 


Fig. 


II.      Quinlan's   Paraf- 
fine Heater. 


28  HYDROCARBON  PROTHESES 

the  syringe  has  never  hampered  any  operator,  the  difficulty  in 
these  instances  having  been  entirely  due  to  the  obstruction 
offered  its  ejection  by  the  thread-hke  plug  obstructing  the 
metal-canula  before  it ;  the  barrel  being  glass  retains  its  tempera- 
ture more  readily  than  the  thin  metal  needle,  hence  the  diffi- 
culty. 

That  all  prothetic  preparation  of  the  nature  in  hand  should 
be  placed  in  the  barrel  of  the  instrument  in  liquid  form  is  es- 
sential, in  that  the  syringe  is  thus  filled  to  its  required  height 
evenly,  and  devoid  of  air  spaces,  yet  in  the  light  of  the  best  and 
most  successful  results  the  mass  should  be  allowed  to  cool  and 
be  ejected  in  semisolid  state  from  a  specially  constructed  in- 
strument to  be  described  later. 

With  such  method  it  is  impossible  to  have  an  occlusion  of 
the  needle  at  any  time  and  the  objection  of  sudden  outbursts  of 
unknown  and  undesirable  quantities  of  the  mass  is  entirely 
overcome. 

15.  Absorption  or  Disintegration  of  the  Paraffine. — The  ques- 
tion of  the  ultimate  disposition  of  paraffine,  injected  subcutane- 
ously  for  any  purpose,  has  been  an  extensive  one  in  which  many 
operators  have  taken  part. 

Gersuny  ^^  at  first  claimed  an  encapsulation  for  the  injected 
mass  of  vaseline,  which  he  states  was  not  taken  up  by  the  lym- 
phatics but  remained  in  situ  as  an  inert,  non-irritating  body. 
Shortly  after  it  was  shown  that  the  encapsulated  mass  soon  be- 
came ramified  by  newly  formed,  fine  bands  of  connective  tis- 
sue which  developed  more  and  more  in  the  part  until  the  entire 
mass  had  become  displaced  by  this  tissue  with  an  eventual  con- 
sistency of  cartilage. 

Eckstein  ''^  claims  that  at  first  a  capsule  of  new  connective 


HYDROCARBON  PROTHESES  29 

tissue  encloses  the  injected  mass  (Hart  paraffine)  a  few  days 
after  the  latter  is  injected,  which  can  be  easily  stripped  away 
from  the  encapsulated  matter  several  weeks  or  months  after, 
showing  a  smooth  inner  wall,  the  encysting  capsule  showing  a 
decided  lack  of  blood  vessels,  proving  histologically  its  relation 
to  the  structure  of  cicatricial  formation. 

In  this  Eckstein  is  undoubtedly  mistaken.  He  objects  to  the 
ultimate  replacement  with  connective  tissue  for  the  vaseline 
process  of  Gersuny,  when  in  reality  we  have  begun  to  realize 
that  such  result  will  follow  any  hydrocarbon  subcutaneous  in- 
jection unless  the  latter  be  made  in  small  quantity  into  parts  of 
the  body  which  are  in  constant  motion. 

The  latter  is  shown  with  injections  of  paraffine  made  into  or 
about  the  nasolabial  fold.  The  tumor  is  so  small  as  to  be 
hardly  felt  by  the  palpating  finger,  but  soon  takes  on  larger 
proportions  evidencing  an  encapsulation  of  some  extent  or  less 
independent  of  the  encysted  mass.  That  this  is  true  can  be 
ascertained  by  incising  these  little  hard  tumors  when  the  con- 
tents can  be  readily  pressed  out  or  evacuated,  the  mass  appear- 
ing practically  as  injected  months  before. 

The  same  result  is  show  by  Harmon  Smith  ""*  who  made  an 
injection  of  paraffine  (iio°F.)into  the  peritoneal  cavity  of  a 
rabbit  which  was  killed  22  days  later.  On  examination  no  sign 
of  inflammation  of  the  peritoneum  was  found — a  fact  that  seems 
to  prove  the  nontoxic  effect  of  paraffine — nor  were  there  evi- 
dences of  the  formation  of  adhesions.  The  mass  had  become 
rounded,  had  travelled  about  the  abdominal  cavity  and  was  found 
lodged  between  the  liver  and  the  diaphragm. 

Comstock^^  with  his  experiences  of  injections  of  paraffines  at 
high  melting  points,  found  that  the  harder  paraffines  do  not  be- 


30  HYDROCARBON  PROTHESES 

come  encysted  but  become  a  part  of  the  new  tissue,  which  be- 
hef  is  corroborated  by  Downie  ^^  who  introduced  paraffine  into 
a  carcinomatous  breast.  Upon  subsequent  amputation  and  mi- 
croscopic examination,  there  was  shown  an  intimate  connection 
between  the  ramified  site  of  the  injection  and  the  surrounding 
tissue.     The  same  results  have  been  noted  by  Juckuff.'^'^ 

Smith  ^^  found,  that  in  trying  to  remove  an  injected  mass  of 
paraffine  several  months  after  introduction,  the  greater  part  of 
the  mass  had  become  so  thoroughly  embedded  in  the  meshes 
of  the  newly  formed  connective  tissue  that  it  was  practically  im- 
possible to  remove  it  without  including  a  considerable  portion 
of  the  connective  tissue  as  well. 

Stein  ^^  claims  also  that  the  paraffiine  is  absorbed,  little  by 
httle,  as  it  is  replaced  by  the  new  connective  tissue,  no  matter 
what  the  melting  point  of  the  introduced  paraffine  might  have 
been.  The  mass  grows  smaller  to  a  degree  according  to  the 
amount  injected  ;  finally  at  the  end  of  a  month  or  more,  the  en- 
tire mass  is  replaced  by  a  tissue  perceptibly  analogous  to  carti- 
lage. 

Freeman,^°  like  Eckstein,  claims  that  encystment  of  the  par- 
affine occurs  soon  after  the  injection,  much  like  that  following  a 
bullet  or  other  foreign  body  in  the  tissues,  but  unlike  the  lat- 
ter author,  that  a  limited  amount  of  the  connective  tissue  also 
penetrates  the  mass  which  is  speedily  converted  into  a  solid 
cartilage-like  body. 

Wendel  ^^  believes  entirely  in  the  encystment  theory,  while 
Hertel,^^  in  specimens  removed  twelve  to  fifteen  months  after 
injection  of  paraffine  with  a  melting  point  of  ioo°  F,  found  a 
wall  of  round  cells  under  various  states  of  inflammation  sur- 
rounding the  masses  with  fibers  of  connective  tissue  traversing 


HYDROCARBON  PROTHESES  31 

the  latter.  In  the  various  histological  findings  he  argues  that 
the  greater  the  tissue  surface  exposed  to  the  injected  foreign 
body  the  greater  the  irritation  and  the  larger  the  smooth  par- 
afifine  mass  the  less  the  reaction,  in  other  words,  small  masses 
of  the  injected  mass  cause  a  higher  rate  of  tissue  formation 
while  the  larger  masses  have  a  tendency  to  encystment  merely. 
He  also  believes  that  the  harder  paraffines  require  a  greater 
length  of  time  to  become  absorbed,  and  that  during  such  time 
of  resorption  new  connective  tissue  growth  is  established  con- 
tinuing to  the  time  of  its  complete  disappearance. 

Comstock  *^  after  thorough  and  extensive  investigation  with 
the  injection  of  paraffines  of  various  melting  points  made  at 
varying  times  after  the  injection  of  such  procedures  concludes 
definitely  that,  "  In  paraffine  we  have  a  substance  that  will  fill 
in  spaces  of  lost  tissue,  and  not  remain  entirely  a  capsulated 
foreign  body,  but  become  a  bridgework  and,  in  fact,  a  part  of 
the  new  tissue." 

Wenzel  *^  after  an  unsuccessful  attempt  to  overcome  a  lap- 
arocele  by  the  injection  of  paraffine,  a  year  later  performed  a 
radical  operation  of  the  parts.  The  excised  tissue  at  the  site  of 
the  injection  showed  deposits  of  the  broken  up  mass  of  paraf- 
fine each  being  enveloped  by  a  capsule  of  connective  tissue 
without  any  signs  of  ramifying  bands  and  hence  decided  against 
the  belief  of  the  resultant  tissue  formation. 

Eschweiler,*^  the  latest  authority  on  the  above  question,  after 
examining  microscopically  a  portion  of  paraffine  injected  tissue 
that  had  been  carried  "  in  situ  "  on  the  bridge  of  the  nose  for 
about  one  year  concurs  absolutely  with  the  connective  tissue 
replacement  belief. 

From  the  foregoing  it  may  be  definitely  accepted  that  while 


32  HYDROCARBON  PROTHESES 

there  may  be  an  encapsulation  or  encystment  of  the  injected 
mass,  be  what  it  may  so  long  as  it  belongs  to  the  paraffine  group, 
there  is  always  a  ramification  of  the  mass  by  the  formation  of 
strands  of  new  connective  tissue  which  eventually  in  a  month 
or  more  according  to  the  amount  of  the  mass,  develops  to  a  size 
corresponding  to  the  latter  or  even  beyond  the  size  of  the  latter 
as  will  be  mentioned  later,  and  that  in  all  cases  the  paraffine  is 
ultimately  and  almost,  if  not  completely,  crowded  out  of  the 
area  occupied  by  the  injection  and  that  its  disappearance  is  ac- 
countable to  absorption. 

This  absorption,  following  such  an  injection,  is  productive  of 
no  harm  to  the  human  economy  and  the  new  tissue  caused  to 
be  formed  by  such  injection  truly  enhances  the  cosmetic  and 
surgical  value  of  the  method  in  as  much  as  an  encapsulated 
mass  of  paraffine  is  liable  to  displacement,  spreading  and  ir- 
regularities should  it  be  subjected  at  any  time  to  external 
violence. 

Such  violence,  again,  would  lead  to  the  irritation  and  inflam- 
mation of  such  cyst  wall  causing  an  undue  crowding  upon  the 
parts  injected  and  possible  gangrene  of  that  part  of  the  wall 
upon  which  such  pressure  was  brought  to  bear,  leading  to  un- 
sightly attachment  and  ultimate  contraction  of  the  skin  where 
bound  down  by  the  inflammation,  or  even  evacuation  by  the  ab- 
sorption of  gangrenous  material  and  resultant  abscess. 

That  this  absorption  or  disintegration  of  paraffine  is  of  no  con- 
sequence may  be  proven  by  all  the  early  cases  in  which  such 
injections  were  used.  Gersuny's  first  case  having  been  done 
May,  1899,  shows  no  diminution  of  the  prothetic  site  at  the 
end  of  two  years.  The  same  may  be  said  of  the  hundreds  of 
cases  done  by  other  operators. 


HYDROCARBON  PROTHESES  33 

The  greater  question  in  the  mind  of  the  author  is  what  will 
be  the  ultimate  behavior  of  this  new  connective  tissue. 

That  the  development  of  this  new  connective  tissue  is  grad- 
ual has  been  mentioned,  some  authors  claiming  a  complete  re- 
placement of  the  mass  at  the  end  of  a  month,  others  from  two 
or  three  months.  Morton  *^  says  that  four  months  time  is  re- 
quired before  the  mass  is,  more  or  less,  completely  removed  and 
replaced  by  organized  tissue.  The  author  believes,  however, 
that  the  length  of  time  necessary  for  this  replacement  not  only 
varies,  proportionately  with  the  amount  of  paraffine  injected  but 
that  it  differs  in  each  case,  and  markedly  with  some  patients  in 
which  the  growth  or  developments  of  the  new  tissue  did  not 
cease  for  months  and  even  a  year  after  such  injection.  This 
corresponds  truly  to  a  hyperplasia  and  will  be  considered  later. 

Time  alone  will  show  the  ultimate  behavior  of  this  new  tissue, 
and  while  it  is  reasonable  to  argue  that  this  newly  organized 
tissue  could  cause  no  untoward  results,  it  must  be  determined 
whether  this  tissue  will  not  undergo  atrophy  and  contract,  or 
become  susceptible  to  other  changes  in  time.  It  is  a  new  tissue 
practically,  and  as  yet  we  know  nothing  of  its  idiosyncrasies, 
although  its  histological  nature  is  determined. 

We  do  not  know  that  irritations,  such  as  surgical  interference, 
will  cause  it  to  take  on  new  growth,  as  evidenced  by  the  at- 
tempts of  extirpation  of  unaccountable  overcorrections  obtained 
with  injections  made  early  in  the  time  of  the  employment  of  the 
Gersuny  method,  in  which  the  parts  practically  grew  back  to 
their  former  size  or  became  even  larger.  This  may  be  ac- 
counted for  by  the  fact  that  most,  if  not  all,  of  the  connective 
tissue  was  not  removed  or  points  to  an  active  nucleus  or  several 
such  centers  which  were  not  destroyed. 


34  HYDROCARBON  PROTHESES 

That  the  growth  is  not  limited  by  the  size  of  the  mass  in- 
jected is  the  author's  behef,  in  other  words,  the  replacement  of 
the  new  tissue  is  not  proportionate  to  the  injection,  but  that 
other  forces,  such  as  adjacent  tissue  pressure  and  presence  and 
outer  influences,  as  for  instance  the  daily  massage  of  the  parts 
with  the  hands  have  much  to  do  with  the  final  amount  of  tissue 
caused  to  be  developed  by  the  initial  stimulus  of  the  injection. 
Nothing  further  or  definite  however  has  been  written  on  this 
supposition. 

1 6.  The  Difficulty  of  Procuring  Paraffine  with  the  Proper  Melt- 
ing Point. 

This  should  not  prove  an  objection  to  the  method,  since 
operators  can  procure  pure  and  sterilized  parafifines  of  the  vari- 
ous melting  points  from  any  reliable  chemical  house. 

What  the  operator  should  determine  first  of  all  is  the  kind  of 
paraffine  he  intends  to  use  for  subcutaneous  injection. 

The  selection  of  paraffine  of  a  certain  melting  point  should 
be  influenced  by  what  he  has  read  on  the  subject  as  given  by 
authorities  of  wide  experience. 

A  few  cases  do  not  suffice  from  which  to  draw  conclusions  ; 
it  is  only  from  a  great  number  of  similar  operations  that  a 
definite  form  or  preparation  of  paraffine  can  be  decided  on. 

From  the  following  authorities  is  shown  a  variance  in  the 
melting  points  of  the  preparations  used,  but  by  a  glance  it  may 
be  noted  that  the  first  division  of  men,  from  numbers  i  to 
lo  inclusive,  use  paraffines  of  melting  points  very  near  to  each 
other  ;  the  latter  group,  from  1 1  to  13  inclusive,  employ  those 
of  the  higher  melting  points. 

The  former  group  may  therefore  be  said  to  utilize  the  par- 
affines of  lower  melting  points. 


HYDROCARBON  PROTHESES  35 

GROUP  I 

1.  Gersuny  " 36-40"  C.     97-104°  F. 

2.  Moskowicz  ^'^ 36-40°  C.     97-104°  F. 

3.  Parker  ^^ 102°  F. 

4.  Freeman  ^° 40°C.    104°  F, 

5.  A.  E.  Comstock^' 107°  F. 

6.  Walker  Downie''- 104-108°  F. 

7.  A.  W.  Morton  ^'^ 109°  F. 

8.  Harmon  Smith''-' 1 10°  F. 

9.  Stephen  Paget ''^ 108-115°  F. 

10.  PfannenstieP'^ 115°  F. 

GROUP  II 

11.  Broeckaert^^ 56°  C.      133°  K. 

12.  Eckstein''^ 56-58°  C.      133-136°  F. 

13.  Karewski*'^ 57-6o°  C.      134-140°  F. 

From  a  glance  of  the  first  group  the  variance  of  the  tempera- 
ture of  melting  points  is  not  a  great  one,  practically  lying  be- 
tween 102  and  115°  F.  approximately.  When  we  consider  the 
actual  difference  in  the  employing  practicability  and  the  effect 
upon  the  tissue  there  is  practically  little,  if  any,  difference. 
The  only  difference  between  these  authorities  is  that  some  em- 
ploy their  preparation  in  liquified  form,  through  the  application 
of  heat,  while  the  others  employ  it  in  the  cold  or  semisolid  form. 
The  choice  of  such  method,  from  what  has  already  been  said, 
should  unreservedly  be  the  employment  of  a  paraffine  in  the 
cold  or  semisolid  form  at  a  mean  temperature  of  about  110°  F. 

This  choice  would  fall  upon  any  one  of  the  paraffines  used  by 
the  authorities  given  in  Group  I. 


36  HYDROCARBON  PROTHESES 

The  objections  to  the  "  Hart  paraffines  "  of  melting  points 
given  in  Group  II  have  been  sufficiently  shown  in  preceding 
paragraphs,  although  a  few  pointed  objections  from  the  various 
surgeons  may  not  be  out  of  place  here  to  offset  the  claims  and 
advocacies  of  those  employing  the  preparation  in  liquid  form  at 
higher  temperatures  than  i  io°  F. 

Paget  ^°°  says,  "  I  am  absolutely  sure  now  that  Eckstein's 
paraffine  is  without  any  real  advantage.  It  is  very  difficult 
to  handle  ;  it  sets  very  rapidly  ;  it  causes  a  great  deal  of  swelling 
and  some  inflammation  and  may  even  produce  some  discolora- 
tion of  the  skin,  and  it  yields  no  better  results  than  does  Pfan- 
nenstiel's  paraffine,  which  melts  at  iio°  F," 

Again  he  says,  "the  best  paraffine  is  that  which  has  a  melt- 
ing point  somewhere  between  io8  and  1 15°  F.  When  the  par- 
affine has  to  stand  heavy  and  immediate  pressure,  the  higher 
melting  point  is  preferable." 

He  had  up  to  the  date  of  the  latter  extract  operated  upon 
forty-three  cases  of  deformed  noses  and  "  in  no  case  was  there 
embolism,  sloughing  of  the  skin  or  wandering  of  paraffine." 

Paget,  however,  employs  the  paraffine  in  liquified  form,  and 
allows  cold  water  to  trickle  over  the  nose  while  the  injection  is 
moulded  into  form.     Of  this  later. 

Comstock  ^°^  says,  "  Paraffine  must  be  used  where  it  will  be  at 
all  time  above  the  body  temperature  "  and  further  that,  "in  select- 
ing the  melting  temperature  for  surgical  uses,  it  should  be  that 
from  106  to  107°  F.  the  best  for  use  in  subcutaneous  injections, 
for  the  reason  that  it  gives  a  substance  firm  enough  to  hold 
very  well  its  form,  especially  when  confined  by  the  surrounding 
tissue,  and' at  the  same  time  with  a  melting  point  out  of  the  reach 
of  the  system  at  all  times." 


HYDROCARBON  PROTHESES  37 

From  this  we  are  given  to  understand  that  he  uses  his  prep, 
aration  in  cold  form  entirely  when  injecting,  but  of  the  melting 
point  mentioned. 

The  author  can  see  no  advantage  in  using  any  paraffines 
of  low  temperature  melting  points  in  liquid  form.  Here  is 
the  very  factor  of  causing  embolism  reintroduced.  Surely  a 
liquid  of  any  kind  injected  into  a  blood  vessel  will  give  cause 
for  trouble,  even  if  the  temperature  of  the  setting  of  such  a  par- 
affine  be  high  or  low.  The  employment  of  the  paraffines  of  a 
melting  point  above  1 20°  F.  in  cold  form  is  difficult,  if  not  im- 
possible, even  with  the  latest  pattern  of  screw  syringe  which  is 
quite  true,  but  there  is  no  need  of  using  such  paraffine  nor  any 
liquified  paraffine  since  any  such  preparation  of  about  the  melting 
point  of  110°  F.  will  serve  every  purpose  overcoming  all  the  ob- 
jections of  the  advocates  of  those  using  any  other. 

If  a  vessel  be  injected  and  filled  with  any  paraffine  preparation 
there  is  danger  of  phlebitis  and  thrombosis,  the  only  possible 
way  to  overcome  it  is  not  to  puncture  the  vessel. 

While  a  preparation  injected  cold  can  be  more  easily  governed 
from  without  by  digital  pressure  or  guidance,  what  can  be  said 
for  a  hot  seething  preparation  introduced  under  great  pressure } 

Furthermore,  when  paraffine  is  injected  in  liquid  form,  es- 
pecially when  so  rendered  by  a  temperature  necessarily  even 
higher  than  the  actual  melting  point,  there  is  danger  of  searing 
the  entire  site  intended  for  injection — a  condition  inducive  to 
no  good  and  a  burning  of  the  skin  where  the  necessary  super- 
heated needle  enters  it,  causing  a  punctate  scar,  more  or  less 
painful  during  the  time  required  to  heal  the  wound. 

With  the  later  knowledge  that  small  amounts  should  be  in- 
jected and  that  such   injections  should  be  repeated,   it  being 


38  HYDROCARBON  PROTHESES 

known  that  such  method  faciUtates  the  production  of  new  con- 
nective tissue  may  we  not  draw  the  conclusion  that  the  result 
obtained  by  the  injection  depends  not  upon  the  injection  per  se, 
but  the  resultant  of  that  injection,  namely  tissue  production  and 
that  this  tissue  production  is  the  outcome  of  a  stimulus  in  the 
form  of  that  injection. 

There  has  not  appeared  an  authority  who  has  claimed  other- 
wise for  injections  of  parafifine  hot  or  cold,  while  it  is  true  that 
the  use  of  liquified  paraffines  at  high  temperatures  have  caused 
all  sorts  of  untoward  results  while  those  of  lower  melting  points, 
in  similar  form  have  not  escaped  objections. 

The  author  has  used  the  cold  injection  method  in  over  300 
nose  cases  without  a  single  case  of  sloughing,  embolism  or  death, 
and  in  no  case  was  there  secondary  diffusion  or  hyperinjection. 
The  only  fault  has  been  the  desire  on  the  part  of  the  patient 
to  be  finished  too  quickly  which  usually  leads  to  a  result  not  as 
satisfactory  as  when  the  injections  are  made  sufficiently  far 
enough  apart  to  allow  the  formation  of  organized  tissue  at  the 
site  of  injection. 

Gersuny's  preparation  of  paraffine,  particularly  useful  for  the 
cold  injection  method,  is  made  as  follows :  A  certain  amount  of 
cold  paraffine  melting  at  about  1 20°  F.  and  white  cosmolin  or 
vaseline,  melting  at  about  100°  F.  are  mixed  by  being  heated  to 
liquification.  The  bulb  of  a  clinical  thermometer  is  then  coated 
with  the  cooled  mixture  of  paraffine  which  is  then  placed  into  a 
hot  water  bath  the  temperature  of  which  is  gradually  raised  un- 
til the  paraffine  melts  and  floats  upon  the  surface  of  the  water. 
The  water  is  then  allowed  to  cool  and  its  temperature  noted 
just  as  the  oil-like  liquid  paraffine  begins  to  look  opaque,  which 
marks  the  melting  temperature  point  of  the  mixture. 


HYDROCARBON  PROTHESES  39 

Should  this  be  found  to  be  too  high  more  vasehne  is  added, 
or  vice  versa  until  the  desired  quantity  of  both  is  known. 

This  method  of  preparation  is  howevera  tedious  and  awkward 
one  and  can  be  readily  improved  upon  by  mixing  certain  known 
quantities  of  the  one  with  the  other  after  the  first  experiment. 

The  author  recommends  the  following  formula  for  the  prepa- 
ration of  a  mixed  parafifine  which  he  has  found  serviceable  and 
satisfactory  for  use  with  cold  process  injections  and  employed 
by  him  for  the  last  four  years, 

(  Parafhne  (plate,  sterile)  5  ii 
(  Vaseline  alba  (sterile)      §  ii 

The  two  are  placed  into  a  porcelain  receptacle  and  melted  in 
a  hot  water  bath  to  the  boiling  point,  then  thoroughly  mixed  by 
stirring  with  a  glass  rod  and  poured  into  test  tubes  of  appropriate 
size  and  allowed  to  cool.  Each  tube  is  sealed  properly  with  a 
close  fitting  rubber  cork  which  may  be  coated  with  a  liquid 
paraffine  without,  including  the  neck  of  the  tube  and  put  away 
for  later  use. 

Since  1905  the  author  has  used  an  electrothermic  heating 
device  in  which  the  paraffine  mixture  is  prepared.  The  apparatus 
is  made  up  of  a  metal  pot  set  into  the  resistance  coil  and  is 
shown  in  Fig.  III. 

This  instrument  overcomes  the  complications  of  the  water 
bath  and  the  burning  or  browning  of  the  parafhne  mixture  so 
commonly  found  with  ordinary  methods.  The  temperature  of 
the  resistance  coil  within  the  heating  chamber  being  controlled 
by  a  small  rheostat  at  will. 

Before  using,  the  contents  of  each  test  tube  thus  prepared  are 
reheated  to  sterilization  and  poured  into  the  barrel  of  the  syringe 


40 


HYDROCARBON  PROTHESES 


to  two-thirds  of  its  length,  the  piston  introduced  and  screwed 
down  into  position  ;  the  syringe  being  placed  to  one  side  until 
its  contents  have  been  cooled,  or  the  entire  instrument  is  im- 
mersed in  sterilized  water  at  about  70°  F,  until  the  paraffine 
mixture  has  set  or  becomes  uniform  in  consistency,  which  takes 
about  5  minutes. 


Fig.  III.     Kolle's  Electric  Paraffine  Heater. 


Upon  screwing  down  the  piston  the  mass  will  be  found  to  issue 
from  the  needle  as  a  white,  cylindrical  thread  and  is  ready^for 
use  in  this  form. 

Harmon  Smith  ^^^  has  had  such  a  parafhne  prepared  which 
has  a  melting  point  of  110°  F,  This  can  be  purchased  in  the 
market  in  sterile  sealed  tubes  ready  for  use.     The  contents  of 


HYDROCARBON  PROTHESES  41 

these  tubes  should  however  be  resterilized  at  the  time  of  em- 
ployment. 

The  same  author  prepares  this  paraffine  of  110°  F.  melting 
point  by  mixing  sufficient  petroleum  jelly  (evidently  white 
vaseline)  with  the  commercial  paraffine  melting  at  about  1 20°  F, 
to  bring  the  melting  point  down  to  110°  F.  He  claims  that 
making  such  a  mixture  is  a  difficult  matter,  since  a  plate  of  par- 
affine will  have  various  melting  points,  one  corner  melting  at 
120°  and  the  opposite  as  high  as  140°  F.  He  advises  having 
the  mixture  accurately  prepared  in  large  quantities  and  dispens- 
ing it  in  test  tubes  of  one-half  ounce  capacity  as  now  found  on 
the  market.  The  mixture  is  poured  in  hot  liquid  form  into 
these  test  tubes  which  are  then  sealed  with  wax  and  placed  on 
a  sand  bath  whose  temperature  is  raised  to  300°  F.  to  insure 
sterilization. 

The  latter  author  has  devised  a  neat  paraffine  heater  shown 
in  Fig.  IV, 

Of  this  he  says,  "  To  insure  still  further  the  sterilization  of 
the  paraffine,  I  have  devised  a  tin  (nickle  plated)  receptacle 
supported  on  an  attached  tripod,  which  raises  the  bottom  an  inch 
from  any  plane^surface  on  which  placed  and  is  closed  with  a  de- 
tachable lid.  This  arrangement  prevents  the  paraffine  from 
burning  or  browning.  Into  this  I  pour  the  paraffine  from  the 
test  tube,  after  melting,  and  place  this  receptacle  into  a  steril- 
izer, or  any  ordinary  boiler — surround  it  almost  entirely  with 
water  and  then  boil.  After  I  have  boiled  it  for  a  few  minutes,  I 
remove  the  receptacle  and  permit  it  to  cool  until  the  paraffine 
therein  is  about  120"  F.  I  then  draw  it  up  into  the  syringe 
which  has  been  sterilized  in  the  same  boiler  with  the  paraffin^. 
When  sufficient  is  withdrawn,  I  evacuate  the  air  bubbles  from 


42 


HYDROCARBON  PROTHESES 


the  syringe  by  pressing  the  piston  upward  and  run  my  set 
screw  into  place.  Some  two  or  three  minutes  are  now  allowed 
for  the  paraffine  to  assume  equal  consistency  throughout  and  to 
cool  down  to  a  semisolid  state.  When  the  paraffine  reaches 
this  consistency  it  may  be  kept  many  hours  ready  for  use,  at 
the  temperature  of  the  room,  if  only  the  precaution  to  warm 
the  needle  is  taken  each  time  before  attempting  the  injection." 


Fig.  IV.     Smith's  Paraffine  Heater. 

17.  Hypersensitiveness  of  the  Skin. — A  permanent  hypersen- 
sitiveness  of  the  skin  over  the  site  of  a  subcutaneous  paraffine 
injection  has  never  been  definitely  shown.  While  it  is  true 
there  is  some  pain  and  feeling  of  stress  and  fullness  over  and 
about  such  area,  immediately  after  the  operation,  this  has  sub- 
sided in  about  twenty-four  hours  in  the  average  case,  except  in 
those  where  a  very  hot  liquid  paraffine  and  of  large  amount  has 
been  injected,  when  several  days  are  required  to  overcome  these 
symptoms. 


HA'DROCARBON  PROTHESES  43 

Smith  ^°^  claims  a  numbness  over  the  site  of  the  injected 
area  which  soon  passes  away,  but  this  is  perhaps  more  a  feel- 
ing of  fullness  rather  than  one  of  anesthesia. 

The  author  has  observed,  however,  in  several  cases  a  period 
of  extreme  discomfort,  fullness  and  cephalagia  in  cases  of  subcu- 
taneous injections  about  the  root  of  the  nose.  Peculiarly  these 
attacks  appear  only  after  the  filling  has  become  organized  that  is 
after  the  connective  tissue  has  displaced  the  paraffine.  The 
secondary  tumor  in  such  cases  appears  to  be  slightly  larger 
superiorly  than  the  original  size  at  the  time  of  injection. 

The  irregularity  of  these  attacks,  with  oedema  of  the  forehead 
and  sHght  puffing  of  the  upper  eyelids,  points  to  a  disturbance 
of  the  circulation  and  is  undoubtedly  due  to  pressure  on  the  an- 
gular vessels,  and  the  venous  arch  across  the  root  of  the  nose. 
The  symptoms  usually  appear  in  the  early  morning  and  moder- 
ate towards  night,  reappearing  again  the  next  morning  or  not 
again  until  the  next  attack  which  may  be  expected  at  any 
time. 

This  condition  of  affairs  is  an  unfortunate  one,  since  we  can- 
not look  to  the  avoidance  of  the  trouble  nor  foresee  it  at  the  time 
of  operation.  In  one  case  the  symptoms  did  not  develop  un- 
til nearly  two  years  after  the  injection  was  made  and  became 
so  troublesome  that  the  only  relief  had  was  by  opening  the  skin 
of  the  nose  laterally  and  excising  as  much  as  seemed  necessary 
of  the  newly  formed  connective  tissue  with  a  fine  pair  of  curved 
scissors.  None  of  the  injected  matter  was  discovered  except 
two  fine  scale-Uke  discs  of  glistening  paraffine  of  a  diameter  of 
one-sixteenth  inch.  These  were  evidently  all  that  remained  of 
the  injected  mass  and  were  undoubtedly  held  in  the  innermost 
meshes  of  the  new  tissue.     Immediate  relief  followed  the  oper- 


44  HYDROCARBON  PROTHESES 

ation  but  no  appreciable  difference  in  the  size  of  the  tumor 
could  be  noticed. 

Cold  applications  or  ice  cloths  relieve  the  temporary  pain  fol- 
lowing an  injection  of  paraffine  but  in  most  cases  this  is  rarely 
necessary  except  in  extremely  nervous  and  expectant  patients. 

On  the  whole  the  author  believes  the  secondary  neuroses 
and  circulatory  difficulties  are  now  practically  overcome  by  the 
more  conservative  use  of  the  matter  to  be  injected,  coupled  with 
a  repetition  of  the  injection  of  smaller  amounts  at  each  sitting 
and  not  repeating  the  same  until  the  first  has  become  organized. 

1 8.  Redness  of  the  Skin. — Redness  of  the  skin  following  an 
injection  of  the  nature  under  consideration  was  one  of  the  early 
objections  made  by  various  operators. 

That  redness  more  or  less  permanent  has  been  found  in  many 
cases  in  which  these  injections  were  made  is  true,  but  such  red 
ness  was  found  particularly  when  the  injections  were  those  of 
liquid  paraffine  of  high  melting  points  and  in  which  the  oper- 
ator was  over-zealous  in  bringing  about  an  absolute  correction  of  a 
deformity,  with  the  result  that  when  the  paraffine  had  been 
moulded  and  set,  it  was  generally  pinched  or  shaped  up  or  out- 
ward thus  causing  a  great  deal  of  pressure  upon  the  circulatory 
vessels  of  the  skin. 

The  redness  in  such  cases  did  not  appear  until  several  days 
after  the  operation  becoming  worse  gradually  instead  of  bet- 
ter even  in  spite  of  the  efforts  to  reduce  it  by  external  ap- 
plications. Not  unusually,  in  the  permanent  cases,  distended 
capillaries  can  be  seen  in  the  skin  resembling  the  condition  in 
acne  rosacea  chronica,  especially  when  the  injection  had  been 
made  to  correct  a  saddle  nose. 

Smith  ^^'^  says,  "  Redness  is  present  in  a  good  many  cases. 


HYDROCARBON  PROTHESES  45 

I  have  seen  a  case  in  which  the  redness  lasted  over  a  year,  but 
it  gradually  disappeared.  There  seems  to  be  a  tendency  on  the 
part  of  nature  to  take  care  of  a  foreign  body,  and  I  think  the 
reinforcement  of  connective  tissue  that  grows  into  this  mass  re- 
quires an  increased  blood  supply,  and  later,  when  the  blood 
supply  is  no  longer  necessary  the  redness  will  disappear." 

The  latter  is  true  where  the  hypersemia  is  either  acute  or 
subacute,  but  in  chronic  cases  where  the  capillaries  have  become 
distended  and  show  plainly  there  is  little  to  be  hoped  through 
the  effort  of  nature. 

Eckstein, ^'^''  the  advocate  of  "  Hart-paraffine  "  method  of  high 
melting  point,  states  that  a  redness  of  the  parts  develops  a  few 
days  after  the  injection  that  disappears  after  a  time,  but  that 
this  redness  is  more  marked  and  of  longer  duration  when  the 
injections  are  made  intracutaneous  instead  of  subcutaneous. 

These  injections  should  be  made  subcutaneous  in  all  cases  and 
there  is  no  excuse  for  deviating  from  this  method. 

With  the  use  of  semisoHd  and  cold  paraffine  mixtures  as  here- 
tofore advocated,  redness  rarely  if  ever  follows  the  injection  un- 
less undue  pressure  has  been  made,  in  which  case  necrosis  is 
more  liable  to  follow  unless  the  adjacent  tissue  will  gradually 
allow  the  mass  to  become  relieved  by  a  change  in  form  and 
position. 

Such  subsequent  hyperaemias  are  not  now  as  common  as  when 
the  injections  were  at  first  attempted  and  the  author  may  say 
freely  that  they  never  occur  when  the  proper  method  and  ma- 
terial is  used, 

Paget  ^"^  says  :  "In  a  few  cases — but  only  in  a  few — some 
reddening  of  the  skin  has  followed  the  injection,  and  in  a  few 
this  has  been  very  slow  to  fade. 


46  HYDROCARBON  PROTHESES 

"  The  few  referred  to  are  of  a  record  of  twenty-two  nasal  cases 
but  no  data  is  given  whether  the  operator  used  paraffine  of  high 
or  low  melting  points.  F.  Connell  found  that  redness  in  that 
case  continued  for  a  year  diminishing  very  little  in  that  time. 
It  appeared  on  the  second  time  after  the  operation  for  a  correc- 
tion of  a  saddle  nose  and  remained  stationary  for  about  one 
month.  Twenty  drops  of  paraffine  were  injected.  It  very 
gradually  increased,  so  gradually  in  fact,  that  there  is  still  a  dis- 
tinct reddened  area  over  the  bridge  of  the  nose.  On  pressure 
this  redness  will  disappear,  but  returns  immediately  after  the 
removal  of  the  pressure.  A  few  dilated  and  tortuous  capillaries 
course  their  way  over  the  area.  The  condition  is  still  present 
fourteen  months  after  the  injection. 

''There  has  been  practically  no  change  or  decrease  in  the  red- 
ness during  the  last  six  or  seven  months,  it  is  not  as  marked 
as  it  was  during  the  first  few  months,  but  still  requires  the  pro- 
fuse application  of  face  powder  in  order  to  prevent  her  nose 
from  being  conspicuously  red." 

The  above  case  has  been  cited  because  it  is  typical  of  such 
condition  and  while  the  amount  as  stated  was  quite  small,  one  is 
almost  nonplused  for  an  explanation  of  the  result,  yet  it  un- 
doubtedly must  have  been  due  to  a  close  attachment  of  the 
skin  to  the  underlying  structures  necessitating  pressure  which 
is  known  to  cause  it. 

However,  it  is  possible  to  have  such  redness  develop  weeks 
or  months  after  the  injections  are  made.  In  such  cases  it  is 
not  due  to  the  primary  pressure  of  the  injection  but  to  that 
of  the  newly  developed  tissue  which  has  taken  its  place  but 
which  is  slightly  overdeveloped  for  the  same  unaccountable 
reason  already  referred  to. 


HYDROCARBON  PROTHESES  47 

Almost  every  surgeon  who  has  used  this  method  of  restoring 
the  contour  of  parts  of  the  face  has  observed  redness,  more  or 
less  permanent,  follow  the  method  used  but  in  most  cases  liquid 
paraffine  of  high  melting  points  had  been  forced  into  the  tissues 
at  great  pressure. 

In  one  case,  that  of  a  southern  operator,  the  entire  tip  of  the 
nose  had  become  injected  by  primary  diffusion  or  direct  fiHing. 

It  became  inflamed  immediately  after  and  some  weeks  later, 
when  the  swelling  had  subsided,  the  lobule  was  found  to  be  very 
hard,  tense  and  extremely  red.  Two  years  after  the  author  saw 
this  case  and  the  tip  of  the  nose  still  appeared  like  a  red  cherry 
with  numerous  capillaries  showing  over  its  area,  while  the  rest 
of  the  nose  although  much  broadened  by  secondary  displace- 
ment of  the  paraffine  was  natural  in  color. 

This  proves  that  as  the  pressure  was  relieved  by  absorption 
and  displacement,  the  tissue  took  on  a  normal  appearance, 
whereas  in  the  lobule  of  the  nose,  where  there  was  no  relief 
from  the  pressure  nature  could  do  nothing  to  reheve  the  inevit- 
able result. 

In  cases  where  the  redness  is  suspected  it  may  not  be  too 
late,  a  day  or  two  after  the  injection,  to  remould  the  mass  into 
such  form  as  to  relieve  the  acute  tension. 

If  the  redness  develops  early,  cold  applications  of  an  anti- 
septic nature  or  ice  cloths  can  be  used  to  advantage.  Anti- 
phlogistine  or  other  similar  preparations  applied  externally  give 
good  results. 

Later  ichtyol,  25^  solution,  may  be  applied ;  acetate  of  alumen 
in  saturated  solution  seems  to  do  well.  Some  operators  apply 
hydrogen  peroxide,  but  it  gives  only  temporary  benefit.  When 
the  capillaries  have  become  distended  and  the  redness  is  prac- 


48  HYDROCARBON  PROTHESES 

tically  chronic  the  vessels  should  be  destroyed  with  a  fine  elec- 
tric needle  using  about  20  milliamperes — direct  current. 

Sometime  when  the  redness  is  acute  and  seems  to  persist  de- 
pletion of  the  part  does  some  good.  This  is  done  by  nicking 
the  skin  here  and  there  with  a  fine  bistoury  and  allowing  the 
part  to  bleed  freely.  Care  should  be  taken  not  to  puncture  the 
skin  too  deeply  so  as  not  to  allow  the  injected  mass  to  escape. 

In  some  cases  it  is  allowable  to  open  the  filled  cavity  early 
and  remove  enough  of  the  filhng  to  overcome  the  difficulty,  in- 
jecting later,  after  the  filling  has  become  organized  to  make  up 
the  deficiency. 

When  the  redness  is  secondary,  that  is  when  it  develops  after 
the  connective  tissue  has  replaced  the  parafifine,  it  is  best  to  open 
up  the  part  and  excise  enough  of  the  tissue  to  overcome  the 
pressure. 

In  a  case  where  the  author  injected  for  a  deep  furrow  in  the 
forehead  with  a  cold  semisolid  paraffine  mixture  a  secondary 
redness  developed  three  months  after  the  injection  had  been 
made,  no  redness  having  been  noticed  in  the  meantime.  There 
was  more  or  less  swelling  for  two  or  three  weeks  undoubtedly 
due  to  pressure  phlebitis  which  eventually  subsided. 

The  redness  in  this  case  was  only  reduced  by  an  excision  of 
the  tissue  causing  the  trouble.     The  result  was  satisfactory. 

19.  Secondary  Diffusion  of  the  Injected  Mass. — This  is  a  con- 
dition that  no  operator  can  foretell,  although  it  might  be  caused 
by  a  primary  diffusion  due  to  hyperinjection  of  so  small  an  ex- 
tent that  it  escaped  the  surgeon's  attention  at  the  time. 

Again  a  site  injected,  may  at  the  time  of  operation,  present 
all  the  indications  of  a  satisfactory  result,  that  is,  the  tissues  at 
the  place  of  operation  and  its  immediate  vicinity  appear  perfectly 


HYDROCARBON  PROTHESES  49 

loose  and  elastic  ;  the  injection  being  made  easily  and  the  con- 
tour of  the  defect  being  remedied  either  partially  or  entirely  as 
the  operator  may  desire ;  there  being  no  mechanical  anaemia 
post-operatio,  and  no  decided  effort  on  the  part  of  the  tissues 
to  cause  primary  elimination  after  the  withdrawal  of  the  needle  ; 
yet  it  is  possible  that,  by  such  an  injection,  sufficient  pressure 
may  be  caused  upon  some  of  the  blood  vessels  within  the  Hm- 
itations  of  the  injection  as  to  cause  a  decided  reaction  a  few 
hours  after  the  operation,  as  evidenced  by  a  swelling,  too  great 
for  the  disturbance  occasioned,  and  associated  with  all  the  signs 
of  a  fairly  active  inflammation. 

It  is  possible  that  such  a  reaction  may  cause  a  displacement 
or  diffusion,  post  primary,  of  the  mass  injected,  especially  if  the 
mass  be  merely  vaseline  or  a  mixture  of  vaseline  and  paraffine 
at  a  melting  point  too  low  for  the  purpose.  Nevertheless,  it  is 
practically  impossible  to  foresee  such  result  and  the  operator 
can  only  use  the  same  care  as  with  any  or  all  such  injections. 

It  is  possible,  when  the  reaction  is  too  marked,  to  mitigate, 
to  a  great  extent,  this  diffusion  of  the  injected  mass,  by  using 
such  methods  as  reduce  the  inflammatory  symptoms. 

As  a  rule  these  cases  exhibit  considerable  ecchymosis  after 
this  active  reaction  has  subsided,  lasting  from  one  to  two  weeks. 

Secondary  diffusion,  as  the  author  uses  the  term,  signifies  an 
extension  of  the  injected  mass  beyond  the  intended  area.  This 
may  occur  in  two  or  three  weeks  or  be  proportionate  to  the  ac- 
tivity of  the  production  of  fibrous  connective  tissue  that  is  sup- 
planting the  mass. 

Leonard  Hill  ^'"  has  reported  a  case  in  which  he  injected 
vaseline  to  correct  a  saddle  nose  for  esthetic  or  cosmetic  rea- 
sons.    The  result  was  very  satisfactory  to  both  operator  and 


50  HYDROCARBON  PROTHESES 

patient  and  continued  so  for  nearly  twelve  months  when  second- 
ary diffusion  of  the  mass  began  to  be  noticeable.  Eventually 
the  diffusion  became  so  great  in  the  upper  eyelids  as  to  close 
both  eyes  completely. 

The  worst  case  of  such  secondary  diffusion  the  author  has 
ever  heard  of  or  seen,  came  to  his  attention  early  this  year. 
The  patient  had  been  subjected  to  a  subcutaneous  injection  of 
oils  for  the  cosmetic  correction  of  an  abnormal  deepening  of  the 
inner  clavicular  notch.  The  injected  mixture,  as  far  as  the  au- 
thor could  learn,  was  made  up  of  sweet  almond,  peanut  and 
olive  oils  with  two  others  that  had  been  forgotten.  Her  physi- 
cian had  made  two  injections  several  days  apart  with  a  satis- 
factory result.  The  reaction  was  trifling  and  the  parts  returned 
to  the  normal  in  two  weeks. 

Five  months  later  the  part  injected  became  tender  to  the 
touch  and  began  to  enlarge  daily.  With  the  increase  in  size  a 
gradual  inflammation  involved  the  whole  lower  region  of  the  an- 
terior region  about  the  root  of  the  neck.  Various  applications 
were  made  to  the  part  to  reduce  the  inflammation,  but  at  the 
end  of  ten  days  a  region  of  skin,  that  had  indicated  the  pointing 
of  an  abscess,  burst,  allowing  the  escape  of  about  eight  ounces  of 
pus.  Under  the  most  careful  surgical  attention  this  discharge 
continued  for  about  three  months,  until  under  the  influence  of 
gauze  packing  the  wound  was  made  to  heal  from  the  bottom 
leaving  an  ugly  irregular  scar  at  the  site  of  the  opening.  With 
the  healing  of  this  fistular  wound,  however,  the  size  of  the  tumor 
did  not  diminish  whatever  but  continued  to  grow  until,  at  the 
present  time,  one  and  a  half  years  after  the  injections  had  been 
made,  the  size  of  this  peculiar  hyperplastic  growth  of  ovate  form 
measures  nearly  five  inches  across  its  horizontal  diameter  and 


HYDROCARBON  PROTHESES  51 

three  and  one-half  inches  through  the  vertical.  It  is  closely 
adherent  to  the  overlying  thickened  skin,  which  has  undergone 
a  yellow  pigmentary  change  to  be  considered  in  the  next  text 
subdivision.  The  tumor  is  hard,  painless  and  freely  movable 
beyond  the  limitation  of  its  skin  attachment  and  rests  upon  the 
sternal  thirds  of  the  clavicles,  extending  upward  and  forward 
with  evidences  of  traction  on  the  whole  anterior  skin  of  the  neck. 
Laryngoscocy  discloses  nothing  abnormal.  The  deformity  is 
hideous  and  necessitates  a  mode  of  dress  to  conceal  it.  The 
patient  has  not  as  yet  been  operated  on  for  the  extirpation  of 
the  growth,  owing  to  her  present  physical  condition,  the  result 
of  melancholia. 

Scanes-Spicer^"^*  injected  some  vaseline  to  correct  a  saddle 
nose  with  satisfactory  immediate  result,  but  after  several  days, 
the  upper  lids  became  slightly  oedematous  and  soon  after  a  small 
hard  lump,  the  size  of  a  grain  of  shot,  was  felt  in  the  left  upper 
lid. 

Harmon  Smith^*^^  observed  a  secondary  diffusion  in  two  cases 
in  which  the  abnormality  in  one  occurred  on  the  side  of  the  nose 
and  in  the  other  at  the  inner  canthus  following  the  course  of 
the  angular  vein. 

While  in  the  foregoing  cases  the  difificulty  may  have  been 
overcome  by  using  the  cold,  semisolid  paraffine  mixture  and  re- 
ducing the  amount  injected,  it  is  questionable  if  the  diffusion 
could  thus  have  been  entirely  overcome. 

The  author  points  to  the  fact  that  undoubtedly  this  fault  is 
observed  more  when  the  tissues  at  the  side  of  the  nose,  or  about 
the  alae,  are  injected  and  that  the  cause  here  is  one  of  an  un- 
equal pressure  of  the  parts — the  skin  more  or  less  bound  down 
above  and  the  ungiving  cartilage  below. 


52  HYDROCARBON  PROTHESES 

In  such  cases  great  care  should  be  exercised  in  the  amount 
injected  and  if,  after  introducing  the  needle,  the  tissue  be  found 
to  be  unduly  adherent  and  inelastic,  to  withdraw  the  needle  and 
with  a  fine  tenotome  divide  or  dissect  up  the  skin  before  the 
mass  is  injected.  At  no  time  would  an  operator  be  justified  to 
inject  more  than  ten  drops  of  the  mass,  at  a  single  operation, 
into  the  parts  referred  to. 

As  already  mentioned,  there  is  not  only  danger  of  diffusion 
of  the  mass  in  such  region  of  the  nose,  including  the  lobule 
and  the  sub-septum,  but  there  is  a  special  danger  of  gangrene 
from  pressure  where  the  tissues  are  less  supportative  than  where 
muscular  tissue  or  greater  mobility  of  the  skin  is  found. 

After  the  immediate  attempts  to  reduce  a  reactive  inflamma- 
tion, nothing  can  be  done  to  overcome  secondary  diffusion  ex- 
cept excision  of  the  amount  not  wanted.  This  should  not  be 
undertaken  until  at  least  three  months  after  the  time  of  injec- 
tion. 

The  mass  of  connective  tissue  must  be  entirely  excised  as 
thoroughly  as  possible,  and  slightly  beyond  the  border  of  the 
abnormal  elevation.  A  sharp  curette  is  practically  of  no  use 
for  this  purpose  and  only  wounds  the  skin,  and  by  reason  of  re- 
tentive shreds  of  tissue  may  cause  infective  inflammation. 

The  opening  into  the  skin  should  be  made  with  a  fine  bistoury, 
the  skin  be  dissected  off  from  the  elevated  connective  tissue 
and  the  latter  extirpated  by  dipping  cuts  of  a  fine  small,  sharp - 
pointed,  half-rounded  scissors.  The  operation  can  be  done 
neatly  and  painlessly  under  Eucaine  anesthesia. 

The  wound  may  be  sutured  with  fine  silk  or  be  allowed  to 
unite  of  its  own  accord. 

It  is  advisable  to  supply  a  small  pressure  dressing,  made  of  a 


HYDROCARBON  PROTHESES  53 

circular  gauze  pad,  over  the  site  to  assure  of  the  best  union  be- 
tween the  dissected  or  undersurface  of  the  skin  and  the  floor  of 
the  wound. 

Dry  dressings  are  to  be  preferred,  since  moisture  would  tend 
to  soften  the  skin  and  permit  it  to  crawl  which  would  not  im- 
prove the  ultimate  result. 

20.  Hyperplasia  of  the  Connective  Tissue  Following  the  Or- 
ganization of  the  Injected  Matter. — The  overproduction  of  con- 
nective tissue  replacing  the  injected  mass  is  rarely  observed,  yet 
a  few  cases  have  been  noted. 

Sebileau  ^^"  has  reported  a  true  case  of  diffuse  fibromatosis 
following  an  injection  of  paraflfine.  This  not  only  included 
the  site  of  the  injection,  but  extended  to  the  surrounding  or  ad- 
jacent tissue,  making  the  secondary  defect  much  more  disfigur- 
ing than  the  first. 

The  author  has  observed  one  case  of  such  an  hyperplasia  fol- 
lowing the  correction  of  a  saddle  nose.  The  area  injected  pre- 
sented no  unusual  appearance  for  six  months  when  the  nose  at 
its  middle  third  began  to  enlarge  slowly  until  it  resembled  a 
marked  Roman  shape,  the  enlargement  extending  laterally  and 
as  far  down  as  the  nasogenian  furrows  at  the  end  of  nine  months. 

The  injection  used  was  a  cold,  semisolid  paraffine  mixture 
and  only  sufficient  to  barely  correct  the  defect  was  injected,  the 
skin  being  thoroughly  flexible  at  the  time  of  operation. 

No  reason  can,  therefore,  be  given  for  this  unusual  result,  ex- 
cept, perhaps,  a  peculiar  idiosyncrasy  of  the  tissues,  that  may 
be  compared,  somewhat,  with  the  external  tissue  changes  in 
hypertrophic  or  keloidal  scars,  especially  noted  in  the  wounds 
of  negroes — a  condition  for  which  we  have,  as  yet,  found  no  at- 
tributable cause. 


54  HYDROCARBON  PROTHESES 

While  we  cannot  definitely  prevent  such  a  result,  following 
an  injection  of  a  hydrocarbon,  we  may  at  least  be  sure  that 
hyperinjection  is  not  the  cause. 

Once  the  hyperplasia  is  estabhshed  the  surgeon  must  simply 
wait  until  he  believes  the  activity  of  the  abnormal  growth  has 
subsided  and  then  remove  the  superabundant  tissue  with  the 
knife. 

With  another  case,  in  which  the  patient  was  operated  on  by 
another  surgeon,  the  author  was  called  upon  to  remove  the 
growth.  A  part  of  the  coarse,  yellowish  pale  and  cartilage  like 
tissue  was  excised,  sufficient  to  restore  the  parts  to  a  normal 
contour.  After  an  uneventful  recovery  the  patient  went  away, 
greatly  pleased,  only  to  return  in  six  months,  presenting  a 
similar  condition  as  before  the  extirpation. 

A  second  operation  was  done,  this  time  more  extensively,  the 
entire  yellowish  connective  tissue  being  removed  by  the  aid  of 
a  long  median  incision  on  the  anterior  aspect  of  the  nose. 

The  wound  healed  readily  and  showed  very  little  scar  and 
the  patient  was  discharged.  One  year  after  the  last  operation 
the  nose  was  still  normal  in  appearance  and  the  growth  had  not 
reappeared. 

From  this  it  is  deemed  absolutely  necessary  to  remove  prac- 
tically all  of  the  newly  formed  tissue  to  warrant  a  nonrecurrence 
of  the  fibromatosis. 

21.  A  Yellow  Appearance  and  Thickening  of  the  Skin  after 
Organization  of  the  Injected  Mass  has  taken  Place. — This  condi- 
tion of  the  skin  is  evidenced  sometime  after  the  injected  mass 
has  become  organized,  beginning  about  the  sixth  month  after  the 
time  of  injection.  It  has  been  especially  noticed  with  the  hard 
paraffine  fillings  of  the  nose  but  also  with  other  injections,  even 


HYDROCARBON  PROTHESES  55 

of  the  lowest  melting  points,  about  the  sterno-clavicular  regions 
of  the  neck. 

The  skin  becomes  at  first  streaked  with  a  superficial  and  ir- 
regularly defined  patch  of  red,  the  forerunning  indication  of  the 
size  of  the  ultimate  pathological  change.  The  red  color  sub- 
sides slowly  leaving  the  area  pale  which  thereafter  gradually 
thickens  taking  on  the  appearance  of  a  light  yellow  stain  in  the 
skin. 

Practically  opposite  to  the  condition  in  xanthalasma,  where 
the  yellow  area  is  slightly  elevated  and  occurs  in  the  loose  tis- 
sue of  the  eyelids. 

The  cause  seems  to  be  a  degenerative  change  in  the  skin  de- 
pendant on  pressure  upon  its  underlying  tissues.  Evidently 
the  pressure  of  an  overproduction  of  the  connective  tissue  which 
has  sprung  up  to  replace  the  injected  mass. 

Seemingly  the  cause  is  due  to  an  injection  being  made  too 
close  to  the  derma  where  the  latter  is  bound  down  to  the  sub- 
cutaneous tissue,  or  a  desire  on  the  part  of  the  surgeon  to  pre- 
vent an  injection  into  the  deeper  areolar  tissue,  especially  when 
the  injection  is  made  in  the  vicinity  of  the  larger  blood  vessels 
for  fearof  causing  embolisms  or  phlebitis. 

Excluding  the  use  of  hard  paraffine  for  such  injection,  the 
operator  should  be  sufficiently  experienced  to  use  these  injec- 
tions properly  and  without  fear,  and  at  all  times  avoid  injecting 
into  the  skin  instead  of  subcutaneously. 

Making  the  puncture  first  and  observing  if  blood  flows  freely 
or  trickles  from  the  detached  needle  will  assure  the  operator 
into  what  tissues  he  has  thrust  his  needle. 

Should  active  bleeding  follow  the  puncture,  he  should  with- 
draw the  needle  and  wait  to  inject  the  site  at  a  later  sitting. 


S6  HYDROCARBON  PROTHESES 

using  the  same  precaution  ;  at  no  time  should  he  be  in  doubt 
as  to  the  absolute  placing  of  the  injected  mass. 

When  the  injections  are  done  about  the  lower  neck  or  shoul- 
ders great  care  must  be  exercised  to  avoid  the  blood  vessels,  and 
small  quantities  be  only  injected  to  prevent  reactions  that  may 
cause  phlebitis  of  these  vessels  ;  furthermore  the  injected  mass 
must  be  carefully  moulded  to  prevent  the  formation  of  uneven 
elevations  or  lumps.  Without  doubt  an  injection  into  one  of 
the  blood  vessels  of  the  neck  would  mean  certain  death. 

Kofman  ^^^  lost  a  patient  by  pulmonary  embolism  24  hours 
after  an  injection  of  10  cubic  centimeters  of  parafhne.  How 
many  punctures  he  made  to  inject  this  amount  is  not  stated,  but 
certain  it  must  be  that  he  introduced  part  of  the  mass  directly 
into  some  blood  vessel. 

The  author  advises,  when  injecting  about  the  neck,  to  use  a 
stout,  dull  pointed  needle  introduced  under  local  ethyl  chloride 
anesthesia  and  to  elevate  the  tissue  with  the  needle  as  the  in- 
jection is  made.  In  this  way  the  operator  can  observe  the  be- 
havior or  placing  of  the  injected  mass,  at  the  same  time  stretch- 
ing the  skin  to  permit  of  the  injection  without  encroaching  upon 
the  blood  vessels.  The  mass  is  immediately  moulded  after  each 
injection.  The  further  question  of  the  practical  method  of  mak- 
ing these  injections  will  be  fully  considered  later. 

If,  however,  the  pigmentation  under  consideration  has  taken 
place,  electrolysis  with  a  fine  needle  may  be  resorted  to,  with  the 
object  of  whitening  the  discoloration  by  producing  scar  tissue, 
in  the  form  of  punctations,  in  the  discolored  area. 

While  the  numerous  white  spots  so  caused  are  objectionable, 
they  are  better  borne  by  patients  than  the  pigmented  appear- 
ance.    A  thorough  needling  of  the  spot  in  this  way  eventually 


HYDROCARBON  PROTHESES  57 

brings  about  an  improvement  and  if,  for  esthetic  reasons,  the 
patient  objects  to  the  unsightliness  of  the  result  thus  obtained 
the  white  area  may  be  carefully  tattooed  with  an  appropriate 
color  to  match  the  rest  of  the  skin  of  the  face  or  neck. 

If  the  pigmented  area  is  not  too  large,  it  can  be  excised  with 
the  knife  and  the  healthy  skin  be  brought  together  with  a 
fine  silk  suture,  thus  leaving  a  thin  linear  scar  which  can  be 
dealt  with  as  the  punctate  scar  area,  if  desired  ;  the  electroylsis 
being  a  painful  procedure  at  all  times,  since  sufficient  milliam- 
peres  must  be  used  to  cause  scar  tissue  formation,  which  is  be- 
tween twenty  to  thirty  milliamperes  in  such  cases. 

22.  The  Breaking  Down  of  Tissue  and  Resultant  Abscess  Due 
to  the  Pressure  of  the  Injected  Mass  upon  the  Adjacent  Tissue 
after  the  Injection  has  become  Organized. 

The  above  result  is  particularly  noticeable  when  the  injections 
have  been  made  into  the  cheek  or  the  breast.  It  is  understood 
that  the  suppurative  changes  under  consideration  herein  are  not 
attributable  to  imperfect  sterilization  of  the  injected  matter,  al- 
though it  is  possible,  and  perhaps  is  the  cause  in  50%  of  the  sup- 
purative elimination  of  the  injected  mass  from  the  cheek,  that  a 
nucleus  of  infection  is  carried  into  the  tissues  and  is  held  in 
suspense  for  a  time,  because  of  its  imbedment  in  a  neutral  me- 
dia that  does  not  readily  permit  of  bacteriological  propagation, 
but  eventually  this  nucleus  must  come  in  contact  with  tissue 
which  it  can  affect,  and  only  then  may  its  infection  be  taken 
up. 

The  author  believes  that  such  secondary  affections  are  ac- 
countable to  pressure  effects  upon  the  blood  vessels  or  glandular 
structure,  as  in  the  case  of  breast  injections,  the  new  con- 
nective tissue  causing  a  lack  of  nourishment  in  the   part  or 


58  HYDROCARBON  PROTHESES 

gland,  and  a  resultant  breaking  down  of  the  tissue,  directly  in- 
fluenced in  some  instances  by  external  violence. 

Tuffier  ^^2  reports  the  elimination  of  paraffine  injected  into 
the  breast  several  weeks  after  the  injection.  If  this  elimination 
had  been  caused  by  primary  infection  an  acute  reaction  would 
have  taken  place  at  least  within  forty-eight  hours,  ending  in 
abscess  shortly  after. 

A  case  which  came  to  the  author's  attention  was  that  of  a 
lady  who  had  been  operated  upon  for  the  correction  of  a  saddle 
nose  three  months  before.  The  result  had  been  satisfactory. 
The  day  previous  to  consulting  the  author  she  had  injured  her 
nose  in  an  automobile  accident.  The  nose  was  much  swollen, 
very  painful  and  red  over  the  entire  upper  and  middle  third. 
The  use  of  external  cold  did  not  relieve  the  condition  much  and 
on  the  fourth  day  the  skin  broke  open  at  one  point  allowing 
pieces  of  the  paraffine  to  escape.  Immediate  relief  followed, 
the  wound  healed  with  a  marked  sinking  of  the  middle  third  of 
the  nose.  After  three  weeks  the  nose  was  again  injected  with 
no  further  untoward  symptoms,  the  result  being  satisfactory  for 
two  years  past. 

In  this  case  undoubtedly  the  exciting  cause  was  directly  due 
to  violence,  which  may  be  the  forerunner  in  many  of  such  cases, 
but  there  is  a  number  of  such  eliminations  directly  due  to  a 
breaking  down  of  the  tissue  from  internal  pressure  alone. 

There  is  no  way  to  overcome  this  difficulty,  except  to  await 
the  definite  formation  of  the  abscess  and  then  to  puncture  the 
skin  directly  over  the  soft  fluctuating  area  and  to  drain  the  cavity. 

Once  relieved,  the  condition  quickly  subsides,  leaving  a  cer- 
tain amount  of  loss  of  contour,  which  can  however  be  corrected 
several  weeks  after  by  a  secondary  injection. 


HYDROCARBON  PROTHESES  59 

When  the  abscess  occurs  in  the  cheek  it  is  not  advisable  to 
open  interiorly,  but  to  make  the  puncture  through  the  skin,  on 
account  of  the  danger  of  infection  from  the  buccal  cavity  and 
of  the  imperfect  evacuation  thus  attained. 

A  trocar  and  canula  of  proper  size  will  be  found  to  be  the 
most  suitable,  the  parts  being  gently  manipulated  to  evacuate 
the  contents  of  the  abscess. 

Aspiration  can  also  be  resorted  to,  but  for  the  breast  a  small 
linear  incision,  made  under  local  anesthesia  at  the  most  depend- 
ant point,  best  answers  the  purpose. 

A  small  gauze  strip  drain  may  be  employed  for  a  few  days  to 
insure  of  perfect  drainage  in  the  latter  case,  the  wound  being 
brought  together  eventually  by  a  delicate  cosmetic  operation  if 
desirable. 


THE  PROPER   INSTRUMENTS  FOR  THE  SUBCUTANEOUS 
INJECTION  OF  HYDROCARBON  PROTHESES 

Although  Gersuny  ^^^  advocated  the  use  of  a  Pravaz  syringe 
for  injecting  the  liquified  vaseline  mixture  for  prothetic  pur- 
poses, it  was  soon  found  that  such  an  instrument  was  practic- 
ally useless,  especially  when  the  parts  to  be  injected  offered 
more  or  less  resistance  to  the  introduction  of  the  foreign  mat- 
ter. 

Other  operators,  following  the  advice  of  Eckstein,^^^  who  ad- 
vised the  employment  of  "  Hart  paraffine  "  of  high  melting  point 
liquified  by  heat,  raised  the  objection  that,  the  metal  needle  be- 
came so  easily  obstructed  by  the  rapid  setting  of  the  paraffine 
in  its  distal  end  that,  the  great  force  necessary  to  eject  the  con- 
tents of  the  syringe  usually  resulted  in  a  breakage  of  the  glass 
barrel  in  the  hands  of  the  operator  or  as  in  some  types  of  the 
syringe  a  separation  of  needle  and  syringe  at  the  point  where 
the  former  was  slipped  upon  the  ground  point  of  the  latter, 
with  the  annoyance  of  the  paraffine  squirting  over  the  faces  of 
both  patient  and  operator. 

Eckstein  tells  us  how  to  overcome  the  first  difficulty  with  this 
same  style  of  syringe  as  used  by  him.  He  covers  the  syringe 
with  a  rubber  insulating  sleeve  and  draws  several  drops  of  hot, 
sterilized  water  into  the  needle  to  overcome  the  plugging  up  of 
the  latter  ;  an  illustration  of  his  syringe  has  been  shown  on 


HYDROCARBON  PROTHESES  6i 

page  26.  Mention  has  also  been  made  of  the  various  methods 
used  to  overcome  this  difficulty  by  other  operators. 

It  was  presently  found  that  such  an  instrument  was  not  only 
impractical  but  also  a  detriment  to  procuring  desirable  results, 
the  paraffine  solution  shooting  out  suddenly,  in  some  instances 
causing  hyperinjection,  and  at  other  times  emerging  so  slowly, 
that  it  required  unusual  force  on  the  part  of  the  operator — a 
painful  procedure  for  delicate  hands  inasmuch  as  the  fingers 
only  can  be  applied  to  operate  the  instrument. 

With  the  object  of  overcoming  this  uncertainty  of  the  amount 
of  the  injection  and  the  unnecessary  exertion  to  inject  any  given 
quantity,  as  well  as  to  establish  enough  vice  a  tergo  to  keep  the 
needle  free  from  plugging  up  with  cooling  paraffine,  various  op- 
erators devised  instruments,  all  having  practically  similar  points 
of  mechanical  merit  and  usefulness.  The  required  necessities 
being  to  invent  a  syringe  which  would  have  a  known  capacity,  a 
piston  under  control  of  the  operator  at  all  times,  and  metallic 
needles  of  proper  lumen,  to  prevent  the  solidification  of  the 
liquid  paraffine,  screwed  to  the  syringe  to  prevent  loosening. 

With  the  object  of  overcoming  these  difficulties  the  author 
devised  a  syringe  which  was  made  for  him  by  Tieman  &  Co., 
early  in  1902,  He  begs  to  introduce  the  same  here,  as  a  type 
similar  to  which  most  operators  have  built  their  special  instru- 
ment. 

The  syringe  at  that  time  consisted  of  a  glass  barrel,  of  a  size 
to  hold  6  c.  c.  of  liquified  paraffine.  At  either  end  of  the 
barrel  tube  were  placed  metal  ends,  the  distal  one  containing  a 
cap  with  a  screw  thread  to  receive  the  needle,  the  upper  cap 
being  threaded  to  receive  a  check  nut  through  its  center  and  on 
its  outer  surface,  on  opposite  sides  to  each  other,  two  metallic 


62  HYDROCARBON  PROTHESES 

rings  to  accommodate  the  thumb  and  forefinger.  The  center 
of  the  check  nut  was  double  threaded  to  receive  the  piston  rod  ; 
the  piston  or  plunger  being  held  in  place  by  two,  upper  and 
lower  washer  nuts,  the  lower  being  threaded  to  receive  a  small 
rod  passing  through  the  bored  out  center  of  the  piston  rod,  and 
which  ended  in  a  check  nut,  in  the  handle,  threaded  upon  the 
outer  or  manual  end  of  the  piston  rod,  in  such  a  way  that  the 
fibre  or  asbestos  piston  washer  could  be  tightened  and  loosened 
at  will. 

The  syringe  permitted  of  being  used  as  an'  ordinary  syringe 
by  unscrewing  the  cap  check  nut  or  be  made  into  a  screw  drop 
syringe  by  screwing  the  same  nut  into  place.  By  turning  the 
handle  end  of  the  piston  rod  the  contents  of  the  syringe  were 
forced  out  smoothly  and  evenly  in  any  quantity  desired. 

With  the  later  employment  of  the  cold,  semisohd  preparation 
of  vaseline  and  paraffine,  as  heretofore  considered,  it  was  found 
necessary  to  reinforce  this  syringe  so  that  the  greater  pressure 
necessary  to  eliminate  the  worm-like  thread  of  hydrocarbon  would 
not  force  off  the  lower  cap  or  break  the  barrel  of  the  syringe  at 
its  needle  end. 

This  was  done  for  the  author  by  the  Kny-Scheerer  Co.,  Dec.  6, 
1902,  when  metallic  strips  were  added  to  opposite  sides  of  the 
glass  barrel  connecting  the  lower  with  the  upper  cap. 

The  instrument  as  then  made  is  shown  in  Fig.  V. 

At  the  same  time  the  same  firm  made  the  author  a  syringe 
entirely  of  metal,  similar  in  construction,  except  that  the  barrel 
was  made  larger  in  diameter  and  shorter  in  proportion  to  bring 
the  instrument  near  to  the  seat  of  operation.  The  regulating 
washer  rod  was  not  needed,  since  in  this  instrument  no  washers 
were  required  the  piston  head  being  made  of  solid  metal  through- 


HYDROCARBON  PROTHESES 


63 


out  and  the  rod  being  soldered  to  the  plunger,  thus  overcoming 
any  objectionable  fault  in  sterilization. 

This  type  of  syringe  was  found  to  be  most  suitable  for  the 


:  mmmwm\^ 


Fig.  V.     Kolle  Screw  Drop  Syringe. 

cold,  semisolid  injections  and  is  of  the  type  now  universally 
used  except  for  the  slight  modifications  of  the  various  operators. 
It  is  illustrated  in  Fig.  VI. 


Fig.  VI.     Kolle  All  Metal  Screw  Drop  Syringe. 

Since  there  were  no  objections  to  making  the  barrel  large 
enough  to  permit  of  injections,  such  as  are  required  for  restoring 
the  contour  of  the  cheek  and  the  neck  and  shoulder,  it  was 


64  HYDROCARBON  PROTHESES 

made  to  contain  lo  cubic  centimeters  working  capacity,  over- 
coming the  necessity  of  constant  refilling,  when  comparatively 
large  injections  had  to  be  made — a  fact  worth  remembering 
from  a  practical  standpoint,  although  two  or  three  of  these  syr- 
inges specially  prepared  for  each  patient,  might  be  found  de- 
sirable by  some  operators.  Yet  the  simplicity  and  ready  facility 
with  which  this  instrument  can  be  used  and  refilled  renders  it 
useful  and  sufficient  for  performing  operations  of  this  nature  to 
any  judicious  extent. 

Syringes  holding  small  quantities  of  the  parafifine  mixture  are 
found  to  be  a  nuisance. 

The  following  operators  employ  syringes  of  the  capacity 
given  : 

Broeckaert  ^^^ 3  c,  c.     50  m.  m. 

Eckstein  ^^^ 5  c.  c.     80  m.  m. 

Freeman  ^^^ 5.6  c.  c,     90  m.  m. 

Downie  ^^^ 10  c.  c.    150  m,  m. 

The  instrument  employed  by  Broeckaert,  holding  less  than 
one  dram,  would  be  of  little  use  except  to  correct  very  slight 
deformities  about  the  brow  or  nose,  or  dressing  up  or  complet- 
ing the  contour  of  parts  previously  filled  by  larger  injections. 

Another  syringe  similar  in  type  to  the  author's,  but  of  a  ca- 
pacity of  5.6.  c.  c.  was  introduced  by  Harmon  Smith.^^^ 

The  principles  of  the  syringe  are  alike,  but  the  style  of 
handles,  two  flat  metal  bars  at  opposite  sides,  offers  an  objec- 
tion when  comparatively  hard  mixtures  of  paraffine  and  vaseline 
are  used. 

While  operating  the  syringe  the  narrow  blades  are  brought 


HYDROCARBON  PROTHESES 


65 


in  contact  with  the  soft  flexor  sides  of  the  thumb  and  forefinger, 
indenting  the  flesh  deeply  and  with  the  least  unexpected  move 
on  the  part  of  the  patient  permitting  it  to  slip  out  of  the  grasp  of 
the  surgeon.  Its  incapacity  for  large  injections  also  offers  some 
objection,  but  for  correcting  smaller  defects  it  is  both  prac- 
tical and  compact.     It  is  illustrated  in  Fig.  VII. 

It  is  obvious  that  with  the  screw  drop  type  of  syringe  the 
cold  semisolid  paraffine  mixture  contained  in  its  barrel  is  always 
under  the  full  command  of  the  operator,  nor  can  there  be  a 
plugging  of  the  needle  since  the  great  force  that  can  be  exerted 


Fig.  VII.     Smith's  Screw  Drop  Syringe. 


with  a  turn  of  the  piston  handle  would  free  it,  even  if  the  mix- 
ture were  of  a  comparatively  high  melting  point,  although  the 
force  to  be  applied  would  naturally  increase  in  proportion  to  the 
hardness  of  the  mass  within  the  syringe. 

The  turning  of  the  screw  piston  forces  out  the  contents  of 
the  syringe  in  the  form  of  a  white  thread  of  a  diameter  equal 
to  the  diameter  of  the  lumen  of  the  needle. 

To  facilitate  this  ejection,  the  needles  should  be  of  ample 
diameter,  not  over  one  inch  long  and  having  knife  edged  points. 


66  HYDROCARBON  PROTHESES 

Longer  needles  are  not  necessary  and  only  add  to  the  force  re- 
quired to  turn  the  screw  handle. 

Curved  needles,  used  by  some  operators,  are  never  needed 
and  the  author  does  not  see  how  they  could  be  applied  at  any 
time  in  preference  to  the  straight. 

As  much  of  the  paraffine  mixture  can  be  forced  out  of  the 
syringe  as  may  be  desired  by  screwing  the  piston  down  into  the 
barrel. 

The  piston  rod  may  be  graduated  in  five  or  ten  drop  divisions, 
but  the  operator  rarely  ever  refers  to  the  scale.  He  judges  the 
amount  required  by  the  elevation  of  the  tissues  brought  about 
by  the  presence  of  the  paraffine  thus  forced  under  the  tissue. 
Experience  soon  teaches  him  the  amounts  necessary  or  judi- 
cious in  each  case,  always  remembering  that  it  is  better  to  do  a 
second  and  later  injection  than  to  hyperinject. 

The  entire  instrument  being  of  metal,  permits  it  to  be  steril- 
ized as  readily  and  in  the  same  manner  as  any  other  metallic 
instrument. 

It  is  understood  that  the  syringe  must  be  taken  apart  for 
sterilization  at  all  times. 

Lubrication,  to  facilitate  operation,  is  never  required  since  the 
nature  of  the  mixture  used  in  the  syringe  answers  this  purpose 
in  every  way. 

Owing  to  the  greater  amount  of  metal  in  the  soHd  piston  it- 
self the  latter  is  very  likely  to  expand  under  dry  heat  steriliza- 
tion or  boiling,  so  much  so,  that  for  a  moment  it  cannot  be  in- 
troduced within  the  barrel.  This  can  be  quickly  overcome  by 
dipping  it  into  cold  sterile  water  or  absolute  alcohol  which  brings 
about  its  contraction. 

After  using,  the  syringe  should  be  emptied  entirely,  unscrewed 


H\'DROCARBON  PROTHESES  67 

and  sterilized  and  placed  in  the  metal  case  furnished  for  it.  A 
screw  cap  is  furnished  to  take  the  place  of  the  needle  when  not 
in  use. 

The  method  of  filling  and  using  the  syringe  will  be  considered 

later. 


PREPARATION  OF  THE  SITE  OF  OPERATION 

The  same  surgical  precautions  should  be  observed  when  a 
paraffine  injection  is  to  be  undertaken  as  with  a  minor  surgical 
operation. 

It  is  hardly  found  necessary  to  prepare  the  site  of  operation 
the  day  before,  nor  need  the  patient  be  detained  for  such  time 
for  the  purpose  of  making  him  ready. 

With  careful  observance  of  ordinary  surgical  technic,  both  as 
to  surgeon  and  patient,  all  of  this  class  of  operations  can  be 
performed  in  any  physician's  office,  providing  that  both  in- 
struments and  the  mass  to  be  injected  have  been  rendered 
sterile. 

Especial  care  should  be  given  to  the  operator's  hands,  for 
with  these  he  not  only  handles  the  instruments  but  must  also 
mould  the  mass  injected,  thus  frequently  coming  in  contact  with 
the  needle  opening  or  openings  made  in  the  skin. 

When  injections  are  to  be  made  in  the  cheeks  of  the  patient, 
the  mouth  should  be  prepared  by  cleansing  the  teeth  thor- 
oughly and  washing  out  the  buccal  cavity  with  warm  boric  acid 
or  hydrogen  peroxide  'solution,  or  any  of  the  preparations  of 
the  Listerine  composition. 

This  rinsing  should  be  continued  every  few  minutes  for  at 
least  ten  minutes  before  the  operation  is  undertaken. 

This  is  necessary  as  the  surgeon  must  introduce  his  finger 


HYDROCARBON  PROTHESES  69 

into  the  mouth  and  behind  the  cheek  to  mould  out  the  mass  in- 
jected subcutaneously  and  infection  could  easily  be  introduced 
by  his  fingers  during  this  procedure. 

Externally  a  generous  field  of  the  operation  is  scrubbed  with 
a  brush  dipped  into  green  soap  and  water. 

The  skin  is  then  thoroughly  washed  with  gauze  sponges 
steeped  in  absolute  alcohol,  followed  with  spongings  with  a 
I  :  5000  solution  of  bichloride  of  mercury.  The  whole  surface 
is  then  wiped  off  with  a  sponge  dipped  in  ether  and  covered 
for  the  time  being  with  a  pad  of  sterilized  gauze  until  the  oper- 
ator is  ready  to  proceed  with  the  operation. 


PREPARATION  OF  THE  INSTRUMENTS  FOR  OPERATION 

The  manner  of  preparing  the  necessary  mixture  of  paraffine 
has  been  described  on  p.  39.  After  such  preparation,  the  mix- 
ture, still  hot,  may  be  poured  into  test  tubes  which  are  sealed 
and  put  away  for  further  use,  each  tube  holding  just  enough  to 
fill  the  syringe  two-thirds  full. 

When  a  syringe  is  to  be  filled,  one  of  the  tubes  is  opened  and 
the  contents  are  again  boiled  over  a  spirit  flame,  or  simply  liq- 
uified and  poured  into  one  of  the  types  of  heaters  already  de- 
scribed for  the  same  purpose  of  resterilization. 

From  the  test  tubes  or  the  heater,  the  boiling  mixture  may 
be  drawn  up  into  the  sterilized  syringe  to  the  required  amount 
or  it  may  be  poured  into  the  opened  piston  screw  cap  end. 

In  the  latter  event  the  ready  cooling  of  the  mixture  as  it  en- 
ters the  needle  will  permit  it  to  be  retained  in  the  barrel,  or 
the  needle  may  be  immersed  in  sterile  water  as  the  paraffine  is 
poured  into  the  syringe,  yet  even  if  a  few  drops  escape  from 
the  needle  in  the  former  method,  no  harm  is  done,  as  such  loss 
amounts  to  nothing  and  helps  to  eventually  fill  the  syringe 
evenly  and  free  of  air. 

If  the  mixture  is  drawn  up  into  the  barrel  to  the  required 
height,  more  or  less  air  enters,  which  must  be  removed  by  turn- 
ing the  syringe,  needle  up,  and  screwing  up  the  piston  rod  until 
either  the  liquid  or  cylindrical  thread  of  the  cooled  mixture  ap- 
pears. 


HYDROCARBON  PROTHESES  71 

If  the  mixture  is  poured  into  the  syringe  the  piston  is  slowly- 
pressed  into  the  barrel,  thus  allowing  the  air  to  escape  along 
its  sides  if  the  mixture  is  set,  or  if  warm  the  syringe  is  turned 
up  and  the  piston  screwed  into  place.  As  this  is  done  the  few 
drops  of  cooled  paraffine  will  be  forced  from  the  needle  before 
the  air  is  exhausted.  The  screw  is  turned  until  the  parafifine 
emerges  evenly  from  the  needle. 

The  syringe  must  now  be  laid  aside,  or  placed  in  sterile 
water  of  the  temperature  of  the  room,  to  allow  the  liquid  within 
to  set  evenly  and  become  uniform  in  consistency. 

The  operator  will  follow  what  method  he  pleases  in  filling 
his  syringe,  but  at  no  time  should  he  fill  it  with  the  cooled  prod- 
uct with  a  spatula,  or  other  such  means,  as  he  is  sure  to  fill  it 
unevenly  in  this  way,  incorporating  a  number  of  air  spaces.  The 
air  issues  from  time  to  time  during  an  operation  with  sudden 
sputtering  outbursts,  that  not  only  tend  to  annoy  the  patient 
but  also  to  frighten  him — the  shock  being  unusual  and  unex- 
pected, while  the  air  thus  forced  into  the  subcutaneous  tissues 
puffs  out  the  parts  and  interferes  with  a  perception  of  the  proper 
amount  to  be  injected  and  adds  to  the  danger  of  air  embolisms. 

Slipshod  methods  are  inexcusable  and  should  not  be  tol- 
erated. The  best  results  possible  should  be  given  the  patient, 
and  only  from  the  best  results  obtained  with  the  best  care  can 
the  most  reliable  data  be  attained,  all  helping  to  fix  the  relia- 
bility, efficacy  and  exactitude  of  this  branch  of  cosmetic  surgery. 


THE  PRACTICAL  TECHNIC 

The  field  of  operation  and  the  instruments  having  been  prop- 
erly prepared  as  described  the  modus  operandi  must  next  be 
considered. 

Since  the  various  parts  of  the  face  to  be  injected  demand 
specific  procedure  they  will  be  considered  somewhat  individu- 
ally hereafter,  whereas  the  general  technic,  applicable  in  as  far  as 
the  method  of  injection  is  concerned  and  applying  similarly  in 
all  cases,  may  tersely  be  first  taken  up. 

Various  and  noted  surgeons  point  out  that  these  subcutane- 
ous injections  should  be  made  under  general  anesthesia,  i.  e., 
ether,  while  others  consider  the  hypodermic  use  of  cocaine  or 
eucaine  ^  solution  in  i  to  4.%  necessary  to  accomplish  good 
results. 

The  author  considers  the  method  in  the  first  case  objection- 
able both  as  to  patient  and  operator  entailing  much  discomfort 
to  the  one  operated  on  and  demanding  an  unnecessary  waste  of 
time  for  the  etherizing  and  recovery.  Likewise  is  the  employ- 
ment of  a  local  anesthetic  not  indicated  nor  demanded,  since 
the  operation  to  be  undertaken  necessitates  only  the  pain  as- 
sociated with  the  prick  of  the  needle  through  the  skin. 

The  objection  to  etherization  is  obvious,  while  the  hypoder- 
mic employment  of  any  local  anesthetic,  by  the  very  fact  of  its 
presence  of  volume  and  its  physiological  action  upon  the  tissue, 


HYDROCARBON  PROTHESES  73 

tends  to  interfere  with  the  proper  injection  of  the  parts  by  rea- 
son of  temporary  svvelhng  of  the  parts,  not  caused  by  the  later 
injections  of  the  prothetic  mass. 

If  in  nervous  irritable  patients  an  anesthetic  is  required  to  al- 
lay fear  it  is  best  to  use  the  ethyl  chloride  spray  upon  the  skin 
sufficiently  to  overcome  the  sharp  sting  of  the  needle  insertion. 
For  this  purpose  the  ether  spray  is  used  only  to  the  point  of 
blanching  the  skin  and  no  longer. 

This  mode  of  procedure  is  especially  useful  when  a  number 
of  injections  are  to  be  made,  as  in  the  rounding  out  of  a  cheek 
or  of  the  shoulders,  in  which  the  contour  cannot  be  restored 
from  one  point  of  injection  as  will  hereinafter  be  described. 

The  patient  being  now  in  readiness,  the  skin  over  the  area  is 
lifted  or  pinched  up  with  the  fingers  of  the  left  hand  of  the  op- 
erator as  a  guide  to  its  mobility  and  to  steady  the  part. 

The  point  of  the  needle  is  now  forced  through  the  skin  and 
into  the  subcutaneous  tissue  at  a  point  along  the  periphery  of 
the  deformity  and  pushed  a  little  beyond  the  center  of  the 
cavity  to  be  filled. 

The  elevation  of  the  skin  is  in  the  meantime  partly  kept  up 
with  the  needle  itself,  while  the  syringe  is  grasped  with  the  freed 
hand,  the  thumb  and  forefinger  of  the  right  hand  being  placed 
upon  the  handle  of  the  screw  or  piston  rod  which  they  must 
rotate  to  force  the  semisolid  mass  from  the  instrument. 

Before  beginning  the  injection  an  assistant  is  instructed  to 
press  with  his  fingers  the  tissue  about  the  margin  of  the  defect 
to  prevent  the  filling  from  becoming  misplaced  or  being  forced 
into  undesirable  channels  especially  if  the  skin  over  the  defect 
is  found  to  be  thick  and  inelastic. 

The   screw  handle   is  now  rotated   evenly  and   slowly,  dis- 


74  HYDROCARBON  PROTHESES 

charging  the  mass  to  be  injected  which  will  soon  be  evidenced 
by  the  rise  of  the  skin  over  the  depression  to  be  corrected. 

Only  sufficient  of  the  mass  must  be  injected  to  fairly  correct, 
never  to  overcorrect,  the  defect. 

Experience  alone  will  assure  the  surgeon  when  this  point  has 
been  attained,  since  he  cannot  immediately  judge  the  necessary 
amount  injected  as  it  will  appear  as  a  round  or  irregular  lump  un- 
der the  skin,  until  it  has  been  moulded  or  worked  out  into  shape. 

Owing  to  the  pressure  exerted  upon  the  contents  of  the 
syringe,  which  will  continue  to  emerge  from  the  needle  for  a 
time,  the  needle  is  left  in  place  for  a  few  seconds  before  with- 
drawal, so  that  the  needle  canal  through  the  skin  will  not  be- 
come filled  with  the  semisolid  mixture. 

Such  blocking  up  of  the  opening  causes  a  cystic  development 
or  enlargment  about  the  opening  in  the  skin  by  this  backing  up 
or  exuding,  ofttimes  crowding  itself  in  between  the  layers  of  the 
skin  and  necessitating  later  removal  with  the  knife.  If  not  this 
fault  it  tends  to  keep  the  wound  open  unnecessarily  after  the 
operation  preventing  healing  and  permitting  the  escape  of  a  cer- 
tain amount  of  the  injected  mass,  if  a  mixture  of  low  melting 
point  has  been  utilized. 

The  needle,  having  been  allowed  to  remain  as  advised,  is  now 
withdrawn.  The  tip  of  one  finger  is  placed  over  the  opening 
in  the  skin  and  held  there  gently,  but  firmly,  while  the  mass  is 
moulded  into  the  shape  required  or  desired  with  the  fingers  of 
the  right  hand. 

If  it  now  appears  that  the  injection  is  insufficient  the  needle 
may  again  be  introduced  through  the  same  opening  and  more 
is  injected,  remembering,  however,  that  if  the  correction  is  quite 
normal  no  more  should  be  added  for  several  days,  or  until  the 


HYDROCARBON  PROTHESES  75 

injected  mass  has  become  organized,  which  should  take  place  in 
about  three  weeks. 

If  it  is  found  that  the  skin  over  the  defect  is  inflexible  and 
bound  down  it  will  be  found  advisable  to  sever  or  disect  sub- 
cutaneously  the  adhesions  that  bind  it  down  with  the  use  of  a 
fine  tenotone  or  a  spear-headed  paracentesis  knife. 

This  may  be  done  two  or  three  days  before  the  parts  are  in- 
jected to  assure  the  surgeon  of  an  absolute  cleanliness  of  the 
wound. 

Mayo^'*'  advocates  the  injection  of  a  saline  solution  into  sub- 
cutaneous wounds  thus  made  as  a  guide  to  the  extent  of  dis- 
section and  to  further  loosen  the  tissues. 

When  the  parts,  thus  loosened,  show  little  tendency  to  bleed 
the  author  advocates  immediate  injection,  as  the  waiting  for 
several  days  permits  the  throwing  out  of  new  connective  tissue 
cells  that  interfere  to  a  certain  extent  with  the  proper  injection 
of  the  part. 

It  is  with  such  wounds  that  secondary  elimination  is  most 
likely  to  take  place,  especially  if  "  Hart  paraffine"  or  parafiine 
of  a  high  melting  point  has  been  employed. 

This  is  undoubtedly  due  to  the  healing  down  and  contraction 
of  the  margins  of  the  wound  which  seems  to  progress  more  and 
more,  encroaching  eventually  upon  the  hard  mass  and  ending  in 
inflammation  of  the  overlying  skin  and  ultimate  illimination. 
With  injections  of  softer  consistency  this  is  less  frequent  and, 
in  fact,  may  be  entirely  overcome  by  limiting  the  amount  of  the 
injection  at  the  first  sitting,  relying  upon  a  full  correction  for 
later  operations,  when  the  periphery  of  the  wound  has  become 
more  or  less  influenced  by  the  presence  of  the  neutral  mass  be- 
tween the  wounded  surfaces. 


76  HYDROCARBON  PROTHESES 

The  subcutaneous  dissection  referred  to  must,  of  course, 
be  done  under  local  anesthesia,  preferably  the  Schleich  mixture 
or  a  1%  solution  of  Eucaine  yg. 

The  injection  of  the  paraffine,  or  hydrocarbon  mixture,  in 
semisolid  form,  having  been  made  and  properly  moulded  into 
shape,  is  set  or  fixed  by  spraying  the  part  with  ether  or  by 
the  application  of  sterile  ice  cloths.  When  liquid  paraffine  has 
been  injected  it  will  be  noted  that  the  paraffine  in  setting  con- 
tracts upon  itself  considerably  leaving  less  of  a  correction  than 
anticipated. 

The  needle  opening  in  the  skin  is  next  washed  off  with  a  2$% 
solution  of  hydrogen  peroxide  and  closed  over  with  a  drop  of 
collodion. 

The  patient  may  then  be  discharged  for  the  time  being,  with 
the  instruction  to  apply  ice  cloths  to  the  part  for  at  least  twelve 
hours  to  reduce,  as  far  as  possible,  the  reactive  resultant  inflam- 
mation. 

On  the  third  day  the  collodion  patch  may  be  removed  and  re- 
placed with  isinglass  adhesive  plaster  applied  with  an  antiseptic 
solution.  The  latter  is  allowed  to  remain  on  the  skin  until  it 
falls  off. 


SPECIFIC  CLASSIFICATION  FOR  THE  EMPLOY- 
MENT AND  INDICATION  OF  HYDROCARBON 
PROTHESES  ABOUT  THE  FACE 

Reference  has  been  made  heretofore  to  the  general  indications 
for  which  subcutaneous  injections  of  paraffine  or  its  compounds 
may  be  employed.  With  the  object  of  systematizing  such  indi- 
cations and  to  further  bring  out  the  practicability  and  judicious 
use  of  the  method  under  consideration  the  author  submits  the 
following  tabulated  arrangement,  with  the  hope  that  it  may  lead 
to  a  more  concise  and  better  knowledge  of  the  possibilities 
within  the  reach  of  the  plastic  or  cosmetic  surgeon. 

The  face  will  be  considered  in  such  grand  divisions  as  are 
easily  and  readily  understood,  the  defects  of  each  part  being 
shown  under  its  distinctive  regional  heading. 

DEFORMITIES  ABOUT  THE  FOREHEAD 

Punctate. 


Transverse  Depressions 

[^  Linear 

Deficient  or  Receding  Forehead  : 

(Exhibition  of  Undue  Superciliary  Ridges). 

r  Traumatic. 
Unilateral  Deficiency  -l 

I   Surgical  (Frontal  Sinus). 


78 


HYDROCARBON  PROTHESES 


Inter-ciliary  Furrow 


Temporal  Muscular  Deficiency 


i 


(  Single 


(^  Multipk 


Unilateral. 
Bilateral. 


DEFORMITIES  OF  THE  NOSE 


Anterior  Nasal  Deficiency 


Lateral  Insufficiency 

Lobular  Insufficiency. 
Inter-lobular  Deficiency. 

Alar  Deficiency 
Subseptal  Deficiency 


Superior  third. 
Middle 
Inferior       " 
Superior  half. 
Inferior       ** 
Total. 

I   Unilateral. 
Bilateral. 


Unilateral, 
Bilateral. 

f  Partial. 


^ 


I    Complete. 


HYDROCARBON  PROTHESES 


79 


DEFORMITIES  ABOUT  THE  MOUTH 

f  Unilateral. 
Upper  Lip  -|   Median. 
1^  Bilateral. 


Labial  Deficiency       -; 


Naso-labial  Furrow 


Oral  Angular  Furrow 


f  Unilateral. 
Lower  Lip  ^'   Median, 
l^  Bilateral. 

f  Unilateral. 

1   Bilateral. 

Unilateral. 


I   Bilateral 


Deficiency  of  Cheek  < 


Total 


Partial 


DEFORMITIES  ABOUT  THE  CHEEKS 

Unilateral, 
i   Bilateral. 

f  Unilateral. 
1   Bilateral. 


Deficiency  of  Lid 
Contour 


Upper  Lid 


Lower  Lid 


DEFORMITIES  ABOUT  THE  ORBIT 

Unilateral. 
I    Bilateral. 

r  Unilateral. 
1   Bilateral. 


8o  HYDROCARBON  PROTHESES 

I   Unilateral, 
Furrow  About  Canthus  -I 

I   Bilateral. 

r  Unilateral. 
Deficiency  of  Ocular  Stump  -l 

I   Bilateral, 

DEFORMITIES  ABOUT  THE  CHIN 

f  Partial. 
Anterior  Mental  Deficiency  -l 

I   Total. 

Lateral  Mental  or  Angular  f  Unilateral. 

Deficiency  |^  Bilateral. 

DEFORMITIES  ABOUT  THE  EAR 

Unilateral. 


Pro-auricular  Deficiency 

i   Bilateral. 

f  Unilateral. 
Post-auricular  Deficiency 

Bilateral. 


SPECIFIC  CLASSIFICATION  FOR  THE  EMPLOY- 
MENT AND  INDICATION  OF  HYDROCARBON 
PROTHESES  ABOUT  THE  SHOULDERS,  ETC. 

r  Unilateral. 

Supraclavicular  Deficiency  -l   _ 

^  ^1   Bilateral. 


HYDROCARBON  PROTHESES 


8i 


Infraclavicular  Deficiency 


f  Unilateral. 
1   Bilateral. 


Interclavicular  (Notch)  Deficiency 


Supra-acromion  Deficiency 


Infra-acromion 


Supra-mammary  Deficiency 


Mammary  Defi- 
ciency 


Partial 


Total 


Supra-Spinous  Deficiency 
Infra-Spinous  Deficiency 


Unilateral. 
I   Bilateral. 

f  Unilateral. 
[^  Bilateral. 

j   Unilateral. 
I   Bilateral. 

Unilateral. 
I   Bilateral. 

Unilateral. 
[_  Bilateral. 
Unilateral. 
Bilateral. 

Unilateral. 
Bilateral. 


Interscapular  Deficiency 


SPECIFIC  TECHNIC  FOR  THE  CORRECTION  OF 
REGIONAL  DEFORMITIES  ABOUT  THE  FACE 
AND  SHOULDERS 

DEFORMITIES  ABOUT  THE  FACE 
TRANSVERSE  DEPRESSIONS 

Punctate  Form. — Such  deficiencies  are  either  of  sharply  de- 
fined depressions  in  a  part  of  the  frontal  bone  due  to  congen- 
ital malformation  or  of  traumatic  origin. 

In  the  first  instance,  they  are  usually  unilateral  or  median 
and  rarely  ever  bilateral.  In  those  of  the  second  class  the  de- 
formity may  be  median  but  is  more  often  found  to  be  unilateral. 

Linear  Depressions  of  the  forehead  are  usually  found  to  be 
congenital,  although  traumatism  in  the  form  of  direct  violence 
may  be  the  cause,  as  for  instance  the  kick  from  a  horse  or  a  se- 
vere blow  or  fall. 

The  acquired  linear  form  of  lack  of  contour  is  found  in  people 
of  middle  life  given  to  undue  use  or  corrugation  of  the  fore- 
head, as  in  frowning. 

The  correction  of  this  class  of  deformities  may  be  accom- 
plished by  carefully  raising  the  depressed  area  by  repeated  in- 
jections of  small  quantities,  always  avoiding  the  frontal  and 
supraorbital  vessels. 

At  no  time  should  such  a  deformity  be  corrected  in  one  sit- 


HYDROCARBON  PROTHESES  83 

ting,  unless  when  the  defect  is  a  congenital  one  of  small  mo- 
ment. 

The  reaction  following  these  injections,  owing  to  the  close 
attachment  of  the  integument  to  the  bone,  is  usually  found  to 
be  more  severe  than  where  the  skin  is  more  loosely  attached. 

In  traumatic  cases  the  scar  attachments  should  be  freely  lib- 
erated, under  eucaine  anesthesia,  by  the  aid  of  a  fine  probe- 
pointed  tenotome,  before  the  cold  paraffine  mixture  is  introduced. 

In  such  event  only  one  opening  should  be  made  and  just 
enough  of  the  mixture  be  injected  to  raise  the  skin  to  its  nor- 
mal contour,  if  this  be  possible.  Generally,  later  injections  are 
required  and  these  may  be  made  without  further  dissection. 
They  should  not  be  undertaken  until  the  incised  wound  made 
with  the  tenotome  has  healed  thoroughly,  otherwise  the  pres- 
sure of  the  injection  is  liable  to  burst  through  the  delicately 
healed  wound  and  thus  delay  if  not  endanger  the  success  of  the 
first  operation. 

When  the  reaction  following  such  injections  be  severe  asso- 
ciated with  considerable  oedema,  cold  pack  or  ice  cloths  should 
be  applied  or  resort  may  be  had  to  hot  applications  of  antiphlo- 
gistine.  The  patient  should  be  kept  on  his  feet  during  the  day 
and  sleep  with  the  head  high  at  night.  The  bowels  should  be 
kept  open  and  general  tonics  be  given  if  indicated.  The  pa- 
tient usually  returns  to  the  normal,  except  for  a  little  tenderness 
about  the  forehead,  in  three  or  four  days  under  the  treatment 
outlined, 

DEFICIENT  OR  RECEDING  FOREHEAD 

In  this  condition  there  is  usually  a  transverse  lack  of  contour 
across  the  forehead  above  the  superciliary  ridges  giving  the 


84  HYDROCARBON  PROTHESES 

patient  a  degenerate  appearance.  The  defect  is  congenital  and 
is  to  be  corrected  as  described  in  the  foregoing  division,  al- 
though the  injections  may  be  at  either  outer  or  temporal  end 
of  the  forehead,  gradually  being  brought  nearer  to  the  median 
line  until  the  contour  of  the  whole  forehead  has  been  raised  by 
subsequent  injections, 

UNILATERAL  DEFICIENCY 

This  defect  may  be  traumatic — the  result  of  direct  violence, 
but  is  more  commonly  due  to  a  frontal  sinus  operation. 

In  both  events  it  will  be  found  necessary  to  detach  the  cica- 
trices that  bind  the  skin  down  to  the  injured  bone,,  before  a 
prothetic  injection  may  be  undertaken. 

In  some  cases  where  the  cause  of  the  deformity  has  been 
moderate  and  the  scar  is  linear  and  of  long  standing  the  injec- 
tion may  be  undertaken  without  subcutaneous  dissection. 

Several  injections  are  necessary,  as  the  tissue  about  such 
parts  is  usually  much  thickened,  apart  from  the  firmness  added 
by  the  scar  tissue, 

A  short  stout  needle  should  be  employed,  the  puncture  be- 
ing preferably  made  under  ethyl  chloride  anesthesia,  as  the  pres- 
sure necessary  to  raise  the  tissue  causes  considerable  pain. 

To  further  facilitate  the  injection  the  operator  should  raise 
the  skin  with  the  needle  introduced  subcutaneously. 

Only  one  injection  of  small  amount  (10-15  drops)  should  be 
done  at  a  sitting.  The  injected  mass,  unless  too  easily  intro- 
duced and  thus  forming  a  tumefaction,  need  not  be  moulded 
out,  since  the  pressure  of  the  skin  overlying  it  will  accomplish 
it  more  satisfactorily,  while  the  pressure  required  in  moulding 


HYDROCARBON  PROTHESES  85 

tends  only  to  press  out  more  or  less  of  the  mass,  thus  lessening 
the  benefit  of  the  operation. 

A  second  sitting  must  be  undertaken  in  not  less  than  one 
week,  or  even  later,  if  a  subcutaneous  dissection  has  been  done. 

The  secondary  treatment  should  be  followed  as  heretofore 
described.  The  reaction,  for  even  a  small  injection  in  these 
cases,  is  usually  considerable, 

INTERCILIARY  FURROW 

This  deformity  is  usually  spoken  of  as  a  frown.  It  may  be 
said  to  be  congenital,  when  it  appears  in  early  life  but  is  com- 
monly acquired  through  the  habit  of  frowning. 

The  furrow  may  be  a  simple  linear  one  or  made  up  of  a  num- 
ber of  furrows.  The  author  has  been  called  upon  to  correct 
one  made  up  of  six  distinct  furrows. 

The  furrows  or  creases  radiate  upward  and  outward,  cone- 
like from  a  point  beginning  at  the  root  of  the  nose. 

In  the  correction  of  this  common  deformity  the  operator  is 
tempted  to  overdo  the  fault  by  hyperinjection.  A  single  furrow 
is  readily  corrected  by  a  few  drops  of  the  injection  which  should 
be  neatly  smoothed  out.  A  little  of  the  mass  at  this  part  of  the 
face  seems  to  accomplish  considerable,  in  fact  the  part  seems 
overcorrected  for  some  time  after  a  judicious  and  carefully  done 
operation,  which  is  undoubtedly  due  to  the  active  reaction  that 
follows  such  cosmetic  procedure  owing  to  the  close  proximity 
of  the  frontal  veins  and  those  of  the  venous  arch  at  the  root  of 
the  nose  which  undergo  more  or  less  phlebitis  of  a  mild  type  ; 
the  resultant  oedema  depending  upon  the  pressure  caused  by 
the  mass  on  these  vessels.     The  intimate  relation  and  anasto- 


86  HYDROCARBON  PROTHESES 

moses  of  the  latter  is  clearly  shown  in  the  carefully  prepared 
dissection  represented  in  the  frontispiece. 

In  injecting,  the  needle  should  be  introduced  at  a  point  di- 
rectly at  the  root  of  the  furrow  or  furrows,  that  is  at  the  junc- 
tion of  the  forehead  with  the  nose. 

A  needle  one  inch  long  should  be  used,  taking  care  not  to 
puncture  any  of  the  veins  which  are  found  to  be  very  differ- 
ently placed  in  various  patients.  If  blood  flows  from  the  needle 
puncture,  no  injection  should  be  made  at  that  point  but  another 
be  chosen  which  does  not  give  such  result,  preferably  at  a  later 
sitting. 

The  needle  should  be  introduced  well  upward  under  the  skin 
so  that  its  point  corresponds  to  the  point  of  greatest  depression. 

The  injection  should  be  made  slowly  and  continued  until  a 
tumor,  judged  to  be  sufficient  to  overcome  the  major  deformity 
when  moulded  out  has  been  formed. 

This  knowledge  can  only  be  gained  by  experience  and  the 
operator  must  be  cautioned  to  underinject  rather  than  cause 
undue  prominence  of  that  part  of  the  face. 

If,  however,  his  judgment  has  not  been  accurate  enough,  the 
operator  can  immediately  thereafter  squeeze  out  enough  of  the 
filling  to  give  him  the  desired  correction. 

If  more  than  a  single  furrow  is  to  be  corrected,  he  may  in- 
ject the  two  center  ones,  leaving  the  outer  for  later  operation. 

In  multiple  furrows  the  injections  must  be  made  in  cone-like 
form,  to  give  a  normal  contour  to  the  forehead.  The  apex  of 
such  cone  corresponding  to  a  point  at  the  root  of  the  nose,  and 
the  base  to  an  arc  with  its  greatest  convexity  near  the  median 
hair  line  of  the  scalp,  depending  upon  the  length  of  the  furrows. 

The  injections  in  such  cases  should  be  made  at  least  three 


HYDROCARBON  PROTHESES  87 

days  apart,  two  being  made  at  each  sitting,  after  the  central  or 
two  inner  depressions  have  been  raised  by  the  first  operations. 
These  later  injections  should  be  made  to  relieve  the  furrows  ly- 
ing next  to  the  median,  gradually  working  out  to  each  slant  side 
of  the  cone  until  the  contour  of  the  middle  forehead  has  been 
made  normal. 

Never  superimpose  an  injection  about  the  median  hne  until 
the  major  defect  in  general  has  been  overcome,  and  only  then 
when  the  first  injections  have  become  settled  and  organized,  as 
such  untimely  disturbance  is  liable  to  set  up  considerable  re- 
action, with  enough  induration  and  resultant  new  connective 
tissue' formation,  to  cause  a  decided  lumpy  or  protuberant  ap- 
pearance of  the  part. 

The  mixtures  of  low  melting  points  should  be  preferred  to 
the  harder  variety  in  frown  corrections.  They  lend  themselves 
to  better  moulding  and  seem  to  undergo  organization  with  less 
pathological  change  than  those  of  the  latter  class. 

When  the  injections  must  be  made  over  the  inner  third  or 
half  of  the  eyebrows,  as  is  often  the  case,  they  should  be  made 
well  above  the  hair  line  and  moulded  out  in  an  upward  direction, 
to  avoid  the  dropping  down  of  the  mass  into  the  upper  lids  or  to 
prevent  the  resultant  displacing  connective  tissue  from  involving 
them. 

If  the  upper  lids  do  become  involved,  as  shown  by  fullness, 
hardness  and  partial  ptosis,  the  connective  tissue  causing  the 
same  must  be  carefully  cut  out  from  the  lid  by  a  transverse 
semicircular  incision  made  in  the  upper  lid  along  the  line  of  its 
backward  fold  or  hinge.  If  need  be,  an  elliptical  strip  of  the 
skin  of  the  lid  may  be  removed  at  the  same  time  to  give  better 
scope  to  the  extirpation  under  consideration. 


88  HYDROCARBON  PROTHESES 

The  author  has  recently  corrected  two  such  cases  where  a 
surgeon  had  hyperinjected  the  entire  forehead  with  a  combina- 
tion of  oils  at  one  or  two  sittings.  The  resultant  involvement 
and  later  discoloration  of  the  lids  at  the  end  of  a  year's  time, 
might  have  been  expected. 

Such  wounds,  when  neatly  sutured  with  No.  i  twisted  silk, 
leave  surprisingly  little  scars,  in  fact  the  cicatrices  are  rarely 
ever  detected  a  few  days  after  healing  has  been  established. 

The  treatment  post-in jectio,  for  all  furrow  protheses,  should 
be  as  already  laid  down. 

Apart  from  general  surgical  cleanliness  and  an  antiseptic 
powder,  the  blepharoplastic  operation  mentioned  required  no 
special  attention.  The  sutures  may  be  removed  in  forty-eight 
hours. 

TEMPORAL  MUSCULAR  DEFICIENCY 

Unilateral  and  Bilateral 

This  facial  defect  while  possibly  unilateral  as  in  hemiatrophy 
is  generally  met  with  in  the  bilateral  form  due  to  either  he- 
reditary causes  or  a  lack  of  nourishment  of  the  parts,  the  latter 
usually  involving  the  greater  part  of  the  face.  Chronic  diseases 
and  the  cachexia  dependent  upon  disease  may  be  the  origin, 
in  which  the  deformity  is  rarely  ever  overcome  entirely  by  in- 
ternal treatment  and  massage  of  the  parts  ;  if  anything,  massage 
tends  to  elongate  the  skin  about  the  temples  causing  a  worse 
disfigurement  in  the  form  of  numerous  fine  furrows. 

The  correction  of  the  defect  under  consideration  may  be 
readily  overcome  by  repeated  and  careful  injections  of  a  hydro- 
carbon of  low  melting  point. 


HYDROCARBON  PROTHESES  89 

The  author  prefers  the  use  of  sterilized  vaseline  injected  in 
its  cold  state.  The  use  of  paraffine  of  high  melting  points  or 
its  compounds  is  not  advisable,  and  if  employed  leaves  the 
temples  uneven  or  lumpy,  due  to  the  unequal  organization  or 
new  tissue  formation  caused  thereby,  at  the  same  time  causing 
sagging  of  the  skin  of  the  adjacent  parts,  particularly,  the  upper 
eyelids  owing  to  the  added  weight  of  the  new  tissue  growth 
occasioned  by  such  preparations. 

Contrary  to  general  expectation  this  part  of  the  face  is  readily 
injected  and  corrected. 

The  skin  should  be  pinched  up  with  the  thumb  and  fore- 
finger of  the  left  hand  and  the  needle  introduced  with  the  right 
hand  in  such  way  as  to  exclude  the  puncturing  of  blood  vessels. 

To  assure  the  operator  against  such  difficulty  the  needle  may 
be  withdrawn  after  insertion  and  if  blood  does  not  trickle  from 
the  wound  it  may  be  reintroduced  without  pain  to  the  patient 
and  the  injection  begun. 

It  is  not  advisable  to  correct  the  defect  at  one  sitting.  One- 
third  or  one-half  of  the  depressed  area  may  be  overcome 
by  one  injection.  The  resultant  tumefaction  must  then  be 
thoroughly  moulded  out,  until  little  seems  to  have  been  accom- 
plished by  the  injection. 

The  operator  trusts  in  these  particular  cases  more  to  the 
development  of  new  connective  tissue  than  in  any  other  part 
of  the  face,  except  perhaps  in  the  correction  of  an  interciliary 
furrow.  It  is  surprising  how  much  is  attained  by  the  most  con- 
servative injections  in  and  about  the  temples. 

The  moulding  of  the  injected  mass  must  be  done  in  a  supe- 
rio-posterior  direction  to  avoid  forcing  it  into  the  upper  eyelids 
resulting  in  the  same  over-development  previously  referred  to. 


90  HYDROCARBON  PROTHESES 

Both  temples  should  be  injected  as  advised  at  one  sitting. 
The  use  of  the  ethyl  chloride  spray  makes  the  operation  less 
fearful  to  the  patient. 

Subsequent  injections  should  not  be  done  earlier  than  three 
weeks  or  until  any  discoloration  of  the  skin  of  the  parts  has  dis- 
appeared. The  latter  is  not  an  unusual  occurence  and  is  un- 
doubtedly due  to  the  pressure  of  the  injected  mass  upon  the 
numerous  blood  vessels  found  there. 

The  post  operative  treatment  should  be  followed  as  here- 
tofore advocated, 

DEFORMITIES  OF  THE  NOSE 

The  use  of  hydrocarbon  protheses  for  the  correction  of  nasal 
deformities  has  revolutionized,  to  a  great  extent,  the  rhinoplasty 
of  many  centuries.  Through  their  employment  many  unsatis- 
factory cutting  operations  have  been  entirely  displaced  and  it  is 
quite  right  to  hold,  that  the  introduction  .of  other  subcutaneous 
protheses  and  like  apparatuses  of  amber,  celluloid,  catchouc, 
silver,  gold,  aluminium,  ivory  or  other  nature  have  been  sup- 
planted by  this  method  of  operation,  when  these  were  needed 
to  correct  a  partial  deformity  of  the  nose. 

When  a  total  rhinoplasty  has  to  be  undertaken  the  paraffin e 
group  of  protheses  of  course  cannot  be  resorted  to,  owing  to  a 
lack  of  the  necessary  retentative  walls  of  tissue,  except  per- 
haps in  such  cases  where  the  so-called  double  flap,  or  French 
method,  is  employed  and  there  only  after  the  parts  have  be- 
come thoroughly  organized. 

A  somewhat  complete  tabulation  of  nasal  defects  has  been 
given  heretofore  which  gives  an  excellent  idea  of  the  extensive 
use  these  hydrocarbon  injections  may  be  put  to. 


HYDROCARBON  PROTHESES  91 

Such  nasal  deformities  as  are  amenable  to  this  method  of 
correction  may  be  due  to  either  congenital  causes,  lack  of  de- 
velopment, direct  violence,  ulcerative  changes  following  catarrh, 
syphilis  and  tubercular  disease.  In  some  cases,  however,  the 
defects  are  purely  of  a  cosmetic  nature,  and  not  considered  as 
abnormalities  except  by  the  critical  eye  of  the  patient.  This  is 
true  particularly  with  lobular  and  supra-alar  deficiencies,  as  well 
as  a  slight  lack  of  contour  about  the  anterior  line. 

In  some  instances,  the  defect  may  be  an  acquired  one,  as  in 
the  lateral  deviation  known  as  handkerchief  bend. 

A  specific  and  somewhat  elaborate  classification  has  been  given 
to  the  more  important  and  distinctive  deformities  of  the  nose, 
principally  to  facilitate  the  proper  citation  and  recording  of 
cases. 

It  may  be  readily  understood  that  each  one  of  these  classifi- 
cations may  be  further  subdivided,  but  such  subdivision  can  be 
only  of  the  degree  or  extent  of  the  deformity  and  must  be  left 
to  the  individual  operator  and  his  thoroughness  of  observation 
and  nicety  of  recording. 

The  author  prefers  making  a  plaster  cast  of  the  entire  nose 
which  is  to  be  corrected  and  a  second  cast  after  the  operation 
has  been  completed,  or  at  the  time  of  his  discharge.  A  record 
sheet,  or  a  direct  photograph  can  be  made  before  and  after  op- 
eration for  the  same  purpose  which  is  not  so  desirable,  how- 
ever, because  it  has  been  found  quite  impossible  to  procure 
the  desired  accurate  pictures  of  a  nasal  deformity,  the  photog- 
rapher not  being  given  to  bringing  out  imperfections  as  the 
surgeon  wishes  them,  even  under  the  most  explicit  instructions, 
unless  the  surgeon  accompanies  the  patient  to  the  studio  to 
supervise  the  posing.     This  requires  a  waste  of  valuable  time  ; 


92  HYDROCARBON  PROTHESES 

not  to  speak  of  the  expense  of  making  pictures  of  a  pathologi- 
cal nature.  The  better  way  would  be  to  have  an  apparatus  in 
the  operating  room.  The  surgeon  can  then  pose  his  patient 
against  a  screen  background  in  the  position  and  to  the  size  of 
picture  he  may  desire.  Plate  cameras  and  time  exposures  are 
best  for  this  purpose.  For  recording  and  half  tone  reproduc- 
tion silver  prints  are  found  best. 

For  all  deformities  of  the  anterior  nasal  line  a  hydrocarbon 
compound  of  the  higher  melting  points  should  be  used.  This 
should  be  injected  in  the  cold  form.  The  mixture  given  on 
page  39,  with  perhaps  an  added  half  dram  or  dram  of  paraffine 
has  been  found  excellent.  The  addition  of  paraffine  being  made 
to  assure  a  suitable  fineness  of  contour  and  width.  The  softer 
mixtures  are  more  liable  to  cause  a  lack  of  contour  and  a  conse- 
quent widening  of  the  part  injected,  even  after  moulding,  be- 
cause of  the  contractility  of  the  skin  overlying  the  injected  mass 
which  tends  to  flatten  it  out  giving  the  nose  a  less  artistic  and 
delicate  appearance. 

Furthermore,  a  soft  mixture  will  be  found  to  be  inefficient  in 
overcoming  the  tension  of  the  skin  in  most  cases,  especially 
those  about  the  middle  third  of  the  nose. 

In  some  cases  of  lateral  deformity,  and  where  otherwise  men- 
tioned, it  is  advisable  to  use  only  a  mixture  of  the  lower  melting 
points  as  in  the  case  in  the  correction  of  interciliary  furrows  and 
temporal  muscular  deficiency. 

Superior  Third  Deficiency.  — The  degree  of  depression  about 
the  superior  third  or  root  of  the  nose  varies  considerably.  The 
most  extensive  form  may  be  commonly  found  in  the  negro  nose 
where  there  is  almost  an  absence  of  a  rise  in  that  part  of  the 
nasal  bones.     Such  noses  are  also  found  in  the  Chinese  and  Jap- 


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a. 

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HYDROCARBON  PROTHESES  93 

anese.  The  condition  ofttimes  may  be  associated  with  epican- 
thiis. 

Epicanthus,  formerly  corrected  by  an  elHptical  excision  done 
anteriorly,  can  be  entirely  overcome  by  the  subcutaneous  injec- 
tion method,  thus  not  only  avoiding  the  resultant  linear  cicatrix 
but  building  up  the  depressed  nose  to  its  normal  contour. 

The  skin  overlying  most  of  the  defects  of  the  superior  third 
is  usually  found  to  be  loose,  hence  injection  is  readily  accom- 
plished. 

The  needle  should  be  introduced  laterally  and  anterior  to  the 
angular  vessels  to  prevent  their  occlusion  and  injection.  The 
point  of  selection  is  made  at  about  the  middle  of  the  deformity. 
The  needle  is  introduced  until  its  point  lies  in  the  center  of  the 
depression,  or  at  the  median  line  from  the  anterior  view. 

The  mass  is  injected  slowly  as  the  skin  of  the  nose  is  pinched 
up  between  the  forefinger  and  thumb  of  an  assistant. 

The  part  is  injected  until  a  tumefaction,  equal  in  body  to  the 
extent  of  the  deformity,  is  attained. 

The  needle  is  allowed  to  remain  in  place  for  a  moment,  to 
permit  of  a  stoppage  of  the  thread-like  mass,  usually  following 
the  pressure  applied  to  the  piston,  after  the  operator  has  stopped 
turning  the  screw.  This  will  prevent  the  mass  from  following 
into  the  channel  made  by  the  needle,  or  the  backing  up  of  the 
mass,  as  it  were.  Should  this  occur  the  paraffine  mixture  should 
be  squeezed  from  the  skin  opening  to  prevent  the  formation  of 
an  inter-cutaneous  encystment. 

Immediately  the  needle  is  withdrawn  the  operator  places  a 
finger  tip  over  the  opening  and  proceeds  with  the  thumb  and 
forefinger  of  the  right  hand  to  mould  the  mass  into  the  desired 
shape. 


94  HYDROCARBON  PROTHESES 

The  post-operative  treatment  should  be  as  previously  given 
and  is  the  same  with  all  injections  about  the  nose,  so  that  it  will 
not  be  referred  to  again  under  this  heading. 

While  a  fairly  large  defect  can  be  corrected  at  one  sitting,  it 
is  advisable  to  rather  reinject  one  or  two  weeks  later  to  secure 
the  exact  shape. 

It  is  to  be  impressed  upon  the  operator  that  there  is  al- 
ways a  slight  broadening  of  this  part  of  the  nose  following  the 
development  of  the  connective  tissue  which  takes  the  place  of 
the  injected  mass,  hence  the  injection  should  not  be  overcrowded 
nor  the  parts  overcorrected. 

The  mass  should  be  moulded  out  as  narrow  as  possible  and 
be  pinched  between  the  fingers  by  the  patient  two  or  three 
times  a  day  after  the  reaction  has  subsided,  which  is  usually 
about  the  third  day.  This  procedure  will  keep  the  mass  from 
being  flattened  during  the  time  tissue  replacement  takes 
place. 

Middle  Third  Deficiency. — This  defect  is  commonly  seen  in 
football  players  and  pugilists  as  the  result  of  a  breaking  of  the 
inferior  extremities  of  the  nasal  bones  and  the  displacement  of 
the  articulating  cartilages,  although  the  defect  is  often  seen  as 
a  result  of  an  injury  to  the  nose  early  in  life,  causing  a  lack  of 
development  in  the  superior  or  articulating  extremities  of  the 
cartilages.  Nondevelopment  frofn  catarrh,  syphilis  and  in- 
tranasal disease  are  other  causes.  This  type  of  deformity  is 
generally  designated  as  the  saddle  nose. 

In  the  latter  cases  the  skin  is  usually  bound  down  to  the 
cartilaginous  structure  by  cicatricial  bands  and  needs  to  be  lib- 
erated. This  is  accomplished  subcutaneously  with  a  fine  teno- 
tome introduced  laterally. 


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HYDROCARBON  PROTHESES  95 

To  assure  the  operator  ot  a  thorough  dissection  he  may  inject 
the  site  with  sterile  water  through  the  opening  made  with  the 
knife,  squeezing  it  out  before  injecting  the  nose. 

If  the  skin  has  had  to  be  freed  by  surgical  means  the  mass 
injected  should  be  sufficient  to  overcome  the  defect  almost  en- 
tirely, to  prevent  the  reformation  of  the  bands  of  connective 
tissue  which  have  been  severed.  Their  re-establishment  would 
mean  an  unequal  development  of  the  new  connective  tissue 
springing  up  from  the  injected  mass  thus  defeating  the  object 
of  the  operation. 

If  no  dissection  has  been  done  the  defect  should  be  corrected 
about  two-thirds  and  added  to  by  a  subsequent  injection. 

The  mass  in  either  case  should  be  well  moulded  out,  espe- 
cially at  both  sides  to  keep  the  nose  as  narrow  as  possible. 
There  will  be  more  or  less  widening  ultimately  following  the 
organization  of  the  mass. 

It  is  not  uncommon  to  find  a  dividing  wall  of  subcutaneous 
tissue  about  the  articulation  of  the  nasal  bones  and  cartilages 
as  evidenced  by  a  rising  up  or  down  of  the  injected  mass  above 
or  below  this  line.  If  this  be  found,  rather  than  break  down 
this  wall  with  the  injection  it  is  deemed  advisable  to  inject  each 
chamber  separately  and  mould  the  two  masses  after  injection 
as  in  the  ordinary  type  of  cases. 

Inferior  Third  Deficiency. — This  deformity  of  the  nose  is  due 
purely  to  a  lack  of  development  or  a  luxation  of  the  cartilage 
of  the  septum  and  the  upper  lateral  cartilages.  The  point  or 
lobule  of  the  nose  is  usually  tilted  upward  and  the  subseptum 
curved  upward  at  its  middle  third. 

The  cause  of  this  deformity  is  usually  due  to  direct  violence 
at  some  time  in  life,  with  improper  replacement  at  the  time  of 


96  HYDROCARBON  PROTHESES 

injury.     Syphilis  and  intranasal  catarrh,  lupus  and  ulcerative 
diseases  are  also  causes. 

The  skin  overlying  the  defect  may  or  may  not  be  closely  ad- 
herent, but  is  in  most  cases  rather  thickened  and  inelastic.  It 
is  therefore  necessary,  in  most  cases,  to  loosen  the  skin  by  sub- 
cutaneous dissection  done  as  already  described  before  the  injec- 
tion is  made. 

To  rebuild  such  a  nasal  defect  without  dissection,  except  in 
such  instances  where  the  skin  is  quite  elastic,  is  not  to  be  ad- 
vised, since  the  injected  mass  would  be  flattened,  more  or  less, 
antero-posteriorly,  giving  the  nose  a  broad  and  ugly  appearance 
after  the  connective  tissue  formation  has  been  attained. 

It  is  with  cases  of  this  kind  that  paraffine  injections  intro- 
duced in  the  liquid  form  and  of  high  melting  points,  are  usually 
expelled  in  a  week  or  ten  days,  or  even  later,  subsequent  to  a 
breaking  down  of  the  surrounding  tissues  and  the  resultant 
abscess. 

The  best  preparation  to  employ  is  the  form  of  paraffine  mix- 
ture advocated  in  the  preceding  operation  used  in  its  cold  state 
and  injected  slowly,  after  the  integument  has  been  rendered 
mobile  enough  to  permit  the  desirable  correction. 

The  defect  should  not  be  corrected  in  one  sitting  for  the 
very  reason  that  some  widening  of  the  nose  may  take  place 
owing  to  the  contractility  of  the  skin,  post-operatio. 

The  mass  injected  should  correct  the  major  part  of  the  defect 
and  be  moulded  out  carefully,  especially  from  both  sides  of  the 
nose  and  the  patient  be  instructed  to  pinch  the  nose  laterally 
several  times  a  day  after  the  reactive  inflammation  has  subsided 
with  the  object  of  keeping  the  nose  as  narrow  as  possible. 

After  the  mass  has  been  thoroughly  replaced  with  connec- 


2: 


< 


HYDROCARBON  PROTHESES  97 

tive  tissue  and  the  anterior  line  is  found  to  be  too  depressed,  a 
fine  line  of  the  mass  about  the  thickness  of  the  needle  may  be 
injected  over  it  in  a  vertical  direction  ;  the  point  of  a  fairly 
large  needle  being  introduced  just  above  the  anterior  aspect  of 
the  lobule  and  thrust  upward  to  the  superior  border  of  the  now 
existing  deformity  and  be  slowly  withdrawn  as  the  mass  is  in- 
jected. 

This  will  leave  a  rounded  cylindrical  like  mass  along  the  an- 
terior nasal  line,  which  must  not  be  moulded  at  all,  except  to 
soften  or  shade  off  the  superior  and  inferior  extremities. 

The  author  advocates  making  two  such  injections,  at  the  same 
sitting  when  the  deformity  has  persisted.  These  injections  are 
made  parallel  to  each  other  with  a  distance  of  about  one-eighth 
inch  between  them. 

The  subseptal  deficiency  will  also  have  to  be  corrected.  This 
will  be  referred  to  later  under  its  separate  division. 

The  reaction  in  cases  of  this  type  is  usually  more  severe  than 
in  those  just  mentioned.  There  may  be  considerable  swelling 
and  discoloration,  but  by  following  the  methods  of  treatment 
laid  down  heretofore  the  symptoms  usually  subside  in  two  or 
three  days. 

Superior  Half  Deficiency. — In  this  type  of  deformity  there  is 
found  a  nondevelopment  of  the  bridge  of  the  nose,  while  the 
greater  part  of  the  cartilage  of  the  septum  and  the  lower  lateral 
cartilages  seem  to  be  quite  normal  in  contour.  The  nose  has  a 
dished  appearance,  with  an  undue  prominence  of  the  nasal  base 
or  lower  half. 

Various  causes  may  be  given  to  this  condition,  but  heredity 
is  responsible  in  a  great  majority  of  the  cases. 

The  deformity  in  the  type  under  consideration  rarely  takes 


98  HYDROCARBON  PROTHESES 

in  an  accurate  half  of  the'nose,  there  being  an  involvement  more 
or  less  of  the  lower  anterior  half,  yet  it  is  sufficiently  distinctive 
to  give  it  specific  classification. 

For  the  correction  of  the  defect  in  such  cases  the  injection  is 
made  laterally,  the  same  mass  being  employed  as  in  the  preced- 
ing cases. 

In  this  type  of  case  the  mass  injected  should  quite  correct 
the  defect  and  be  moulded  with  great  care  to  a  desired  contour, 
keeping  in  mind  always  the  condition  and  elasticity  of  the  skin 
overlying  it. 

An  inflexible  skin  should  be  rendered  mobile  by  digital  mas- 
sage, practiced  for  a  few  days  prior  to  operation,  or  in  tense 
conditions  be  loosened  by  subcutaneous  dissection. 

The  great  fault  in  injecting  so  large  a  quantity  as  is  neces- 
sary in  these  cases,  is  to  make  the  nose  too  wide  from  the  very 
beginning,  which  added  to  the  widening  following  the  replace- 
ment by  new  tissue,  makes  the  shape  of  the  nose  unsatisfac- 
tory. 

For  this  reason  it  will  be  found  of  some  benefit  to  apply  an 
anterior  nasal  splint  of  aluminium,  covered  interiorly  with  a  fold 
of  white  flannel  or  gauze  and  pressed  into  such  shape,  that  when 
applied  to  the  nose  it  will  keep  the  latter  pinched  up  laterally  to 
the  desired  width.  This  splint  will  hardly  ever  be  borne  by  a 
patient  and  causes  great  discomfort  until  after  the  post-opera- 
tive reaction  has  subsided.  It  may  then  be  bandaged  or  held 
in  place  by  strips  of  Z.  O.  Adhesive  plaster  for  an  hour  or  two 
in  the  day  and  during  the  entire  night. 

After  the  first  few  days'  wearing  the  patient  soon  becomes  ac- 
customed to  the  splint.  It  should  be  worn  as  mentioned  for 
about  three  weeks,  when  the  patient  may  be  permitted  to  pinch 


HYDROCARBON  PROTHESES  99 

the  nose  laterally  with  his  fingers  two  or  three  times  a  week  or 
more. 

The  secondary  injection  may  be  made  in  the  ordinary  way  or 
as  advocated  by  the  author  in  the  manner  described  in  correct- 
ing defects  of  the  inferior  third  of  the  nose. 

Inferior  Half  Deficiency. — In  this  type  of  deformity  the 
greater  point  of  nondevelopment  or  deficiency  is  found  at  the 
upper  extremity  of  the  cartilage  of  the  septum,  below  its  artic- 
ulation with  the  inferior  border  of  the  nasal  bones,  and  involving 
to  a  greater  extent  the  area  over  the  upper  lateral  cartilages. 

This  deformity,  due  to  whatever  cause,  rarely  affects  the  base 
or  inferior  part  of  the  nose  owing  undoubtedly  to  the  greater 
protection  and  stability  offered  by  the  lower  lateral  and  sesa- 
moid cartilages  and  the  dense  cellular  tissue  making  up  the 
alae.  Except  in  such  cases  where  violence  of  an  extreme  na- 
ture has  been  exerted  in  early  life,  or  where  ulcerative  disease 
has  broken  down  most  of  the  cartilage  of  the  septum,  the  point 
of  the  nose  is  usually  normal  in  size  and  shape.  In  the  latter 
cases  there  is  an  upper  tilt  of  the  lobule  and  a  shortening  of 
the  calumna  upon  itself  with  a  convexity  in  an  upward  direc- 
tion. 

The  cause  of  this  type  of  deformity  is  usually  a  direct  blow 
upon  the  point  of  the  nose,  syphilitic  ulceration  internally,  ca- 
tarrh or  other  ulcerative  disease. 

When  due  to  violence  the  point  of  the  nose  may  or  may  not 
present  a  normal  appearance,  there  may  be  a  normal  base  tilted 
upward  (retrousse  or  snout  nose)  or  a  dropping  forward  and 
downward  (hook  or  beak  nose). 

The  shape  of  the  nasal  base  depends  much  upon  the  time 
of  life  the  injury  was  received,  that  is  before  or  long  after  pu- 


loo  HYDROCARBON  PROTHESES 

berty,  also  upon  the  extent  of  injury  inflicted  and  where  ap- 
phed. 

From  injuries  received  early  in  life  we  may  look  to  a  lack  of 
development  in  the  cartilage  of  the  septum  alone,  or  associated 
with  deficiency  in  one  or  both  lateral  cartilages. 

The  deformity  is  usually  symmetrical,  but  where  the  nasal 
bones  have  been  injured  as  well,  particularly  where  one  bone  is 
injured  more  than  its  fellow,  there  is  a  possibility  of  the  disfig- 
urement being  unilateral.  This  is  rarely  the  case  except  when 
due  to  punctured  wounds  ;  generally  in  such  cases  the  anterior 
nasal  line  assumes  a  twisted  form. 

Some  operators  have  included  noses  of  undue  lobular  prom- 
inence (a  la  Cyrano  de  Bergerac)  under  this  type  of  deformity 
and  while  it  is  to  be  admitted  such  a  nose  might  be  built  up  by 
subcutaneous  prothesis  the  result  is  anything  but  harmonious 
or  normal.  Such  a  nose  should  be  reduced  by  cutting  opera- 
tions instead  of  being  added  to.  The  seeming  depression  above 
the  lobule  is  only  comparative  to  the  overdeveloped  form  of  the 
lobule.  The  face  values  of  every  patient  should  be  studied  and 
the  surgeon  should  never  attempt  to  break  up  the  harmony  of 
facial  form  by  simplifying  an  operation  and  rendering  the  pa- 
tient's appearance  even  more  ridiculous  than  before  his  attempt 
to  correct  a  fault. 

The  correction  of  the  deficiencies  of  the  lower  half  of  the 
nose  is  associated  with  difficulties  in  various  directions.  Either 
the  skin  over  the  defect  is  too  dense  to  render  injection  an  easy 
matter,  or  the  nose  is  so  broadened  horizontally  from  the  orig- 
inal injury  that  the  injection,  no  matter  how  artistically  done, 
leaves  the  nose  bulky  and  ugly  in  appearance. 

When  the  nasal  processes  of  the  superior  maxillary  bones 


HYDROCARBON  PROTHESES  loi 

have  not  been  widened  unduly  by  an  injury  and  the  skin  is  dense, 
simple  subcutaneous  dissection  before  injection  will  overcome 
the  difficulty  easily  enough. 

In  that  case  the  needle  is  inserted  laterally  in  a  line  with  the 
maximum  depth  of  the  depression  and  the  point  shoved  up  to 
the  median  line  anteriorly. 

Enough  of  the  cold  mixture  of  paraffine  and  vaseline,  as 
heretofore  advised,  is  injected  to  reduce  the  deformity  nearly 
to  the  normal. 

The  mass  is  moulded  to  give  the  nose  as  near  a  normal  con- 
tour as  possible  always  keeping  in  mind  the  later  broadening  of 
the  nose  when  the  new  connective  tissue  has  taken  the  place 
of  the  injected  mass.  A  later  injection  made  as  advised  here- 
tofore will  restore  the  anterior  line  to  better  form. 

If  the  nasal  processes  of  the  superior  maxillary  bones  have 
been  thrown  outward  considerably  a  surgical  operation  is  neces- 
sary to  reduce  them. 

No  injection  should  be  made  until  the  wounds  from  such 
operation  are  thoroughly  healed  and  contracted. 

In  all  cases  of  this  type  the  skin  will  be  found  to  be  rather 
dense  and  likely  to  be  tied  down  by  past  inflammations  to  the 
anterior  aspects  of  the  lower  lateral  cartilages  at  their  juncture 
with  the  upper  lateral  cartilages.  If  the  adhesions  are  not  too 
dense  the  harder  form  of  the  cold  mixture  should  be  used.  This 
will  not  only  permit  of  raising  the  skin  more  readily  than  with 
a  softer  kind  of  mixture,  but  will  be  more  likely  to  retain  its 
form  under  the  contractile  pressure  brought  to  bear  down  upon 
it. 

When  the  skin  is  closely  adherent  it  should  be  loosened  sub- 
cutaneously  as  already  advised.     The  injection  may  be  done  at 


I02  HYDROCARBON  PROTHESES 

the  same  sitting  and  be  of  greater  quantity  than  in  the  cases 
where  this  had  not  been  done,  for  the  reasons  mentioned. 

Pressure  spHnts  and  manual  compression  should  be  employed 
as  in  the  preceding  deformity. 

The  reaction  following  the  first  injection  is  likely  to  be  severe. 
Cold  applications  as  previously  referred  to  are  indicated  and 
should  be  continued  for  at  least  two  days. 

Care  should  be  taken  not  to  inject  into  the  lateral  vessels 
which  usually  lie  on  a  line  with  the  juncture  between  the  lateral 
and  lower  lateral  cartilages.  If  this  should  happen,  the  point  of 
the  nose  at  once  assumes  a  bluish  hue,  there  is  more  or  less 
pain  felt  at  once,  with  considerable  swelling  a  few  hours  after 
the  injection.  Later,  every  symptom  of  gangrene  of  the  lobule 
is  liable  to  be  noticed,  yet  with  faithful  attention  to  furthering 
the  circulation  of  the  parts  by  either  cold  or  hot  applications, 
the  active  inflammatory  symptons  usually  subside  in  ten  to  four- 
teen days,  leaving  the  patient  with  a  whole  nose,  more  or  less 
colored  at  the  lobule  according  to  the  state  of  the  circulation 
and  the  exposure  of  the  parts  to  the  various  temperatures.  This 
may  be  overcome  in  time,  yet  it  may  persist  for  years,  depend- 
ing entirely  upon  the  ability  of  the  anastomosing  vessels  to 
overcome  the  artificial  thrombus  or  occlusion  offered  by  the 
mass  injected. 

That  a  reaction  quite  similar  in  character,  but  of  milder  de- 
gree, is  likely  to  be  seen  when  one  of  these  vessels  have  not 
been  injected,  can  be  readily  understood  when  we  consider  that 
a  hard  and  somewhat  ungiving  mass  is  made  to  overlie  the  ves- 
sels themselves.  The  symptoms  just  described  in  such  case  are 
apt  to  be  noted  much  later,  even  several  hours  after  the  injec- 
tion, because  the  swelling  has  then  begun  to  add  its  pressure  to 


H. 


'I. 


< 


HYDROCARBON  PROTHESES  103 

that  of  the  mass  in  obstructing  the  flow  of  blood  to  the  lobule. 
Such  condition  may  be  termed  pressure  occlusion  in  contradis- 
tinction to  thrombotic  obstruction. 

These  symptons  usually  subside  in  a  day  or  two,  or  with  the 
swelling  caused  by  the  reaction. 

If  the  symptoms  appear  at  once  after  the  injection,  it  is  best 
to  force  out  as  much  of  the  injected  mass  as  is  possible  through 
the  needle  hole  through  which  it  has  been  introduced. 

The  author  was  called  to  attend  a  case  several  hours  after 
the  operator  had  injected  a  nose.  The  acute  symptoms  pointed 
to  a  direct  occlusion  of  the  vessels,  yet  the  surgeon  who  had 
performed  the  operation  assured  me  he  had  not  injected  until 
he  found  that  blood  did  not  flow  from  the  needle  after  its  inser- 
tion. To  relieve  the  patient  of  immediate  fright  and  some  pain, 
a  dull  pointed  needle  of  larger  calibre  than  the  one  used  in 
operation,  was  pushed  through  the  needle  wound  previously 
made,  taking  the  place  of  a  canula,  and  a  greater  part  of  the 
injected  mass  was  squeezed  out.  Ice  cloth  applications  were 
followed  through  the  night  and  the  nose  recovered  in  three  days 
without  showing  the  discoloration  of  the  skin  usually  observed 
following  such  cases.  The  nose  was  never  injected  again,  on 
account  of  the  dread  of  the  patient,  but  peculiarly  the  anterior 
line  showed  almost  a  normal  contour  after  four  weeks  had 
elapsed.  This  only  goes  to  prove  that  very  much  less  of  the 
mass  to  be  injected  is  required  than  is  commonly  supposed  by 
operators. 

Total  Anterior  Deficiency. —  In  this  condition  there  is  a 
scooped-out  or  general  curved-in  appearance  of  the  entire  ante- 
rior nasal  line.  The  lobule  of  the  nose  is  usually  normal  in 
size. 


I04  HYDROCARBON  PROTHESES 

This  defect  should  be  corrected  by  two  injections  of  the  par- 
affine  compound  previously  referred  to.  The  points  of  injection 
should  be  lateral  and  anterior  to  the  angular  vessel  on  the  side 
of  the  nose  preferred  by  the  operator.  One  about  the  center  or 
major  curvature  and  the  other  about  the  inferior  third. 

Care  should  be  taken  to  mould  the  injected  mass  as  narrow 
as  possible,  or  as  much  as  the  skin  will  permit.  If  the  latter 
is  bound  down  it  should  be  mobilized  by  subcutaneous  dis- 
section or  levation.  A  subsequent  injection  should  not  be  un- 
dertaken until  the  entire  mass  has  become  settled  or  fairly  or- 
ganized, which  is  about  the  end  of  three  weeks. 

The  mass  should  be  injected  well  up  to  the  root  of  the  nose 
to  give  it  the  appearance  of  the  normal  bridge.  If  this  is  found 
impossible  owing  to  a  dividing  skin  attachment,  a  third  needle 
puncture  should  be  made  at  a  point  on  a  level  with  the  inter- 
nal canthus. 

Care  must  be  exercised  to  keep  the  mass  from  creeping  into 
the  loose  tissue  about  the  internal  canthi  by  having  an  assistant 
press  the  sides  of  the  nose  at  that  point  with  the  thumb  and 
forefinger. 

This  undesirable  condition  is  much  more  liable  to  occur  when 
a  hot  liquid  paraffine  is  employed,  since  the  operator  can  observe 
quite  accurately  the  extent  and  direction  taken  by  the  mass  in- 
jected when  the  cold  product  is  used. 

Some  authorities  have  injected  noses  of  this  type  from  the 
point  of  the  nose,  but  it  will  be  found  that  the  position  of  the 
puncture  at  this  point  allows  a  considerable  portion  of  the  mass 
to  work  out  during  moulding  and  also  to  permit  of  the  readier 
oozing  out  of  the  mass  during  the  pressure  exerted  by  what  re- 
active inflammation  follows  the  operation.     This  is  accounted 


03 


03 
O 


c 


HYDROCARBON  PROTHESES  105 

for  by  the  fact  that  the  needle  creates  a  tube  Uke  canal  in  the 
tightly  bound  down  tissue  overlying  the  lower  lateral  cartilages, 
whereas  in  the  lateral  punctures  the  short  canal  is  easily  dis- 
placed by  the  swelling,  thus  causing  its  obUteration  and  prevent- 
ing the  free  oozing. 

On  the  other  hand,  it  will  be  found  to  be  more  difficult  to  in- 
ject from  the  point  of  the  nose  alone  and  that  a  very  long  needle 
has  to  be  used  which  must  be  withdrawn  as  the  parts  above  the 
point  are  filled.  Furthermore,  it  will  be  found  necessary  to 
thrust  the  point  of  the  needle  in  different  directions  to  overcome 
vertical  attachments  of  the  skin  which  are  more  readily  lifted 
up  than  thrust  aside  by  the  mass,  hence  necessitating  a  greater 
amount  of  injury  to  the  tissues,  not  to  speak  of  the  possibility 
of  injecting  transverse  blood  vessels  higher  up  in  the  nose  of 
which  the  operator  would  not  be  aware  at  the  time ;  showing 
only  in  the  resultant  phlebitis  and  unexpected  reactive  symptoms, 
associated  with  a  discoloration  more  or  less  lasting  according  to 
the  extent  of  obliteration  of  the  vessels. 

The  post-operative  treatment  should  be  as  heretofore  ad- 
vised. 

Lateral  Insuflaciency — Unilateral  and  Bilateral. — Depressions 
about  the  sides  of  the  nose  are  usually  due  to  hereditary  causes, 
when  they  are  hkely  to  be  bilateral,  yet  intranasal  ulcerations 
may  cause  a  falling-in,  as  it  were,  of  either  one  or  both  nasal 
walls,  involving  in  such  instances  the  entire  side  or  part  of  it. 
In  the  partial  cases  the  depression  may  be  in  any  of  the  division 
of  thirds  used  by  the  author,  that  is,  it  may  lie  laterally  over 
the  region  of  the  nasal  bone  and  such  of  the  nasal  process  of 
the  superior  maxillary  bone  as  goes  to  make  up  that  part  of  the 
nose,  or  in  the  middle  third  below  the  bone  structure  and  above 


io6  HYDROCARBON  PROTHESES 

the  superior  limitation  of  the  lower  lateral  cartilages,  or  within 
the  lower  third  over  the  inferior  border  of  the  cellular  tissue 
making  up  the  nasal  rim. 

Traumatism  may  be  found  to  be  the  cause  of  such  depressions, 
especially  in  the  middle  third,  after  fracture  or  luxation  of  the 
nose.  In  such  cases  the  defect  is  usually  unilateral  or  at  the 
seat  of  the  former  injury,  a  convexity  usually  being  exhibited 
on  the  opposite  side. 

Since  the  skin  is  rather  firmly  adherent  at  the  sides  of  the  nose, 
except  in  the  major  part  of  the  superior  third,  it  will  be  found 
best  to  raise  the  skin  of  such  defect  into  normal  contour  by  a 
series  of  very  small  injections  instead  of  following  the  method 
heretofore  advised  in  connection  with  tense  or  adherent  areas 
of  skin,  for  the  reason  that  such  dissection  would  render  the 
skin  too  mobile  over  an  area  usually  beyond  the  defect  itself  and 
inviting  the  surgeon  to  an  annoying  hyperinjection  which  ren- 
ders the  part  more  unsightly  than  prior  to  the  operation.  This 
is  true  in  most  cases  unless  the  depression  is  of  traumatic  origin 
and  beyond  the  size  of  deformity  usually  corrected. 

The  author  advocates  the  employment  of  a  hypodermic  needle 
attached  to  the  syringe  in  place  of  the  regular  needle  and  that 
the  injection  be  of  sterile  white  vaseline  without  additions  of 
any  kind. 

Such  injections  may  be  made  very  readily,  one  or  more  at 
the  first  sitting,  being  introduced  below  the  deepest  part  of  the 
defect.  It  is  surprising  how  much  four  or  five  drops  of  such  an 
injection  will  accomplish.  Furthermore,  it  is  to  be  remembered 
that  the  injections  about  the  side  of  the  nose  are  readily  replaced 
by  new  connective  tissue,  equal  to,  if  not  commonly  greater  in 
amount  than  the  mass  injected,  such  growth  being  completed 


HYDROCARBON  PROTHESES  107 

in  about  two  months  after  the  time  of  injection.  This  may  be 
explained  by  a  more  or  less  active  perichondritis  when  the  in- 
jection is  made  over  the  cartilage,  the  inflammation,  thus  set  up, 
being  of  longer  duration  than  where  skin  and  bone  or  areolar 
tissue  are  involved.  Any  subsequent  injection  should  not  be 
undertaken  until  at  the  end  of  two  weeks  or  more  for  the  rea- 
sons above  stated. 

The  injected  mass  at  all  times  should  be  introduced  under 
normal  pressure,  never  to  the  extent  of  rendering  the  skin  above 
it  white  in  color.  The  mass  should  also  be  moulded  out  with 
the  tip  of  the  finger  or  the  rounded,  dull  handle  end  of  a  scalpel. 
If  necessary,  the  small  finger  may  be  introduced  into  the  nos- 
tril to  facilitate  this  moulding.  Should  the  reactive  inflamma- 
tion be  severe  such  remedial  agents  as  have  been  referred  to 
should  be  used  to  reduce  it. 

Phlebitis  following  injections  at  the  side  of  the  nose  is  due 
entirely  to  the  injection  of  a  blood  vessel  and  must  be  avoided. 
When  a  fine  needle  is  used  there  is  less  likelihood  of  free  bleed- 
ing from  an  injured  vessel,  therefore  a  thorough  knowledge  of 
the  usual  position  of  the  vessels  about  the  sides  of  the  nose  is 
absolutely  essential.  Bleeding  of  greater  extent  than  that  which 
would  follow  the  thrust  of  the  needle  through  the  skin  should 
put  the  surgeon  on  his  guard.  Experience  is  the  better  teacher 
and  conservatism  in  these,  ofttimes  delicate,  subcutaneous  op- 
erations will  save  the  surgeon  much  annoyance  and  eventually 
the  need  of  having  the  patient  submit  to  a  cutting  operation  to 
reduce  an  overcorrected  area. 

Should  a  hyperplasia  of  connective  tissue  result  from  such  an 
operation,  a  small  linear  incision,  under  4%  eucaine  anesthesia, 
should  be  made  directly  over  the  greatest  prominence,  through 


io8  HYDROCARBON  PROTHESES 

which  the  offending  mass  can  be  removed  by  the  aid  of  a  small 
hooked  knife  or  a  fine  pair  of  curved  scissors. 

The  mass  should  be  removed  beyond  the  plane  of  the  skin, 
in  fact  it  should  be  rather  removed  in  cone-like  form,  apex  in- 
ward, and  the  peripheral  attachment  completely  obliterated,  in 
order  to  obtain  the  desired  result,  as  it  is  not  unusual  to  have 
the  prominence  reappear  after  imperfect  extirpation  and  im- 
proper dissection. 

Moist  pressure  dressings  may  be  applied  over  the  small  wound 
thus  made,  for  several  days,  or  until  the  inflammation  following 
the  operation  has  subsided.  Suturing  such  a  wound  is  hardly 
necessary,  but  if  the  incision  be  over  one-fourth  of  an  inch  long* 
two  fine  silk  sutures,  deeply  placed,  may  be  utilized,  their  ten- 
sion adding  to  the  compression  needed  to  bring  the  mobiUzed 
skin  into  position  in  reference  to  the  base  of  the  wound. 

The  author  has  used  contractile  collodion  in  place  of  compress 
dressings  with  very  good  result.  This  should  be  renewed 
within  forty-eight  hours. 

After  eight  or  ten  days  silk  isinglass  adhesive  plaster  is  ap- 
plied over  the  wound  until  it  falls  off. 

Lobular  Insufl&ciency. — This  defect  of  the  nose  is  usually  of 
hereditary  origin  although  it  may  be  occasioned  by  the  retrac- 
tion of  the  inferior  half  of  the  organ  in  tubercular  or  syphilitic 
ulceration  in  which  the  lobule  falls  inward  and  upward  by  the 
loss  of  the  retaining  cartilages. 

Owing  to  the  close  adhesion  of  the  skin  to  the  lower  lateral 
cartilages  and  the  cellular  tissue  about  the  rim  of  the  alae  it  is 
found  difficult  to  restore  the  contour  or  elongate  the  organ  at 
that  site  by  subcutaneous  injection. 

Even  after  thorough  mobilization  of  the  integument  the  sub- 


HYDROCARBON  PROTHESES  109 

sequent  injected  mass  is  liable  to  be  thrown  off  by  an  overac- 
tive inflammatory  reaction,  due  undoubtedly  to  the  adhesions 
formed  between  the  divided  surfaces  from  the  periphery  inward 
which  has  a  tendency  to  crowd  the  injected  mass  forward  and 
downward  before  a  new  connective  tissue  has  had  time  to  be 
formed,  causing  a  breaking  down  of  the  skin  at  some  point  over- 
lying the  mass  and  allowing  it  to  escape. 

The  author  has  attempted  to  replace  the  injection  by  small 
solid  paraffine  plates  introduced  through  a  small  lateral  incision 
made  for  the  subcutaneous  dissection,  and  while  the  wound 
healed  readily  enough  and  the  nose  appeared  normal  the  plates 
were  in  every  case  thrown  off  by  a  later  inflammatory  process 
before  the  end  of  the  third  week. 

The  author  then  attempted  to  replace  the  solid  plates  with 
granular  paraffine,  gently  packing  the  latter  into  the  wound  un- 
til the  desired  elevation  had  been  obtained  with  the  idea  that 
such  mass  would  accommodate  itself  much  better  under  the 
pressure  caused  by  reactive  inflammation,  but  even  this  pro- 
cedure proved  unsuccessful. 

The  best  results  are  obtained  with  sterilized  white  vaseline 
injections  when  there  is  considerable  mobility  of  the  skin.  A 
single  needle  opening  should  be  made,  preferably  about  the 
center  of  the  side  of  the  lobule,  or  slightly  anterior  to  this  point, 
carrying  the  point  of  the  needle  forward  to  the  anterior  medium 
line  and  a  little  above  the  actual  point  of  the  nose. 

The  injection  should  be  made  slowly,  closely  watching  the 
size  of  the  elevation  caused  by  the  mass  and  the  state  of  the 
circulation  about  the  entire  lobule. 

Usually  ten  drops  of  the  mass  suffice  to  give  the  desired  re- 
sult.    The  mass  may  be  moulded  out  if  found  desirable,  but  if 


no  HYDROCARBON  PROTHESES 

the  skin  appears  normal  after  the  operation  and*  the  tumefac- 
tion thus  made  does  not  make  the  nose  look  grotesque  it  may  be 
allowed  to  remain  as  injected,  depending  upon  the  subsequent 
reactive  pressure  to  force  it  into  shape.  In  this  way  a  greater 
part  of  the  mass  is  retained  at  the  wanted  site  and  is  not 
crowded  to  the  sides  of  the  lobule  by  the  customary  post-opera- 
tive moulding. 

Even  with  this  method  great  care  must  be  exercised  in  not 
injecting  too  much  at  each  sitting.  A  failure  is  sure  to  result 
in  hyperinjection  about  the  lobule.  When  it  be  remembered 
that  only  a  very  small  quantity  of  the  mass  will  make  a  decided 
difference  the  surgeon  and  patient  should  be  satisfied  with  the 
slightest  gain. 

If,  however,  the  mass  be  retained  and  further  elongation  of 
the  lobule  is  desired  a  subsequent  injection  can  be  undertaken, 
but  not  until  a  full  month  after  the  primary  operation. 

Here,  as  with  lateral  nasal  injections,  there  seems  to  be  an 
overproduction  of  new  connective  tissue  following  such  an  in- 
jection ;  a  decided  factor  in  eventually  pleasing  the  patient. 

It  is  needless  to  say  that  the  operator  must  avoid  injecting 
one  of  the  blood  vessels  of  the  lobule  as  this  will  cause  consid- 
erable inflammation  from  which  the  lobule  does  not  recover 
readily,  owing  to  the  dense  tissue  the  surgeon  has  to  deal  with, 
leaving  the  tip  of  the  nose  discolored  and  bluish  for  some  time 
after  the  operation. 

If  the  injected  mass  causes  an  immediate  venous  stasis  of  the 
lobule  hot  applications  should  be  apphed  at  once,  or  as  soon  as 
the  operator  discovers  that  the  proper  massage  and  pressure  to 
remove  the  offending  mass  does  not  improve  the  circulation. 

The  author   advocates  the  judicious  use  of   antiphlogistine 


HYDROCARBON  PROTHESES  iii 

faithfully  applied  hot  every  six  hours  and  continued  until  the 
acute  inflammatory  symptoms  subside,  when  the  surgeon  may 
resort  to  ice  cloths  or  cold  pack  until  the  danger  of  pressure 
and  resultant  gangrene  have  subsided. 

Despite  the  very  grave  symptoms  associated  with  such  in- 
flammation the  operator  may  assure  the  patient  against  perma- 
nent disfigurement,  although  the  three  or  four  weeks'  duration 
of  treatment,  usually  required  in  such  cases,  is  an  ordeal  the 
cosmetic  surgeon  and  the  patient  is  not  liable  to  forget. 

If  the  injected  mass  causing  this  state  of  affairs  has  been  of 
liquid  parafline,  the  better  method  to  pursue  is  to  make  several 
small  incisions  into  the  site  of  the  injections  and  remove  the 
little  masses  of  solid  paraffine  as  far  as  possible  with  the  view 
of  relieving  the  pressure  or  encroachment,  at  the  same  time  al- 
leviating the  pain  and  stasis  by  the  resultant  depletion.  Moist, 
hot  applications  should  follow  this  procedure.  The  small  wounds 
made  in  the  skin  will  heal  without  suture  leaving  hardly  any 
perceptible  scar. 

The  author,  however,  advises  against  any  mixture  or  liquid 
paraffine  injections  about  the  lobule,  never  having  seen  a  satis- 
factory result  when  either  had  been  employed. 

The  post-operative  treatment  in  uncomplicated  cases  may  be 
of  aristol  and  adhesive  isinglass  plaster  or  collodion. 

Interlobular  Deficiency. — This  condition  is  hereditary  in  the 
great  majority  of  cases.  The  defect,  while  quite  disfiguring 
giving  the  appearance  of  a  cleft  nasal  point,  is  easily  corrected 
by  the  subcutaneous  injection  method. 

Paraffines  of  high  melting  points  should,  however,  never  be 
employed  for  this  purpose  for  diverse  reasons  : — first,  the  hard- 
ening of  the  mass  after  cooling  causes  too  much  pressure  upon 


HYDROCARBON  PROTHESES  113 

reactive  symptoms  are  not  severe  if  proper  technic  has  been  ap- 
plied and  cold  compresses  usually  relieve  it  within  twenty-four 
hours. 

Should  the  skin  be  adherent  about  the  anterior  aspect  of  the 
lower  lateral  cartilages  it  can  be  forced  away  with  a  small,  dull, 
round  pointed  knife  resembling  an  eye  spud,  the  opening  for 
which  need  not  necessarily  be  greater  than  that  made  for  the 
needle.  The  latter  is  inserted  through  the  same  opening  which 
must  be  closed  over  in  this  event  with  a  drop  of  contractile  col- 
lodion into  which  aristol  is  introduced  with  the  pulverflator, 
which  not  only  embodies  an  antiseptic,  but  at  the  same  time 
hastens  its  hardening. 

Alar  Deficiency — Unilateral  and  Bilateral. — The  contraction 
about  the  nasal  rims  may  be  due  to  hereditary  causes  or  the  re- 
sult of  intra-nasal  disease.  The  defect  is  usually  bilateral  involv- 
ing the  entire  alas  or  only  their  lower  half  or  third. 

The  fault  should  be  corrected  by  several  injections  made  along 
the  rim  of  the  nasal  wing  using  a  fine  needle,  preferably  of  the 
hypodermic  size.  Vaseline  only  should  be  used  and  two  or  three 
drops,  according  to  the  extent  of  the  deformity,  be  injected  into 
the  cellular  tissue  at  the  point  of  each  needle  insertion. 

Three  of  such  punctures  may  be  made  along  the  rim,  one  be- 
yond the  other  in  each  wing.  According  to  the  defect  the  injec- 
tion may  be  carried  higher  or  lower  above  the  margin  of  the  rim 
by  shoving  the  needle  upward  and  toward  the  inferior  border  of 
the  lower  lateral  cartilage. 

The  reaction  in  these  cases  is  very  little,  rarely  necessitating 
other  than  an  antiseptic  powder-plaster  dressing.  Subsequent 
injections  should  be  made  if  the  first  do  not  give  the  desired 
contour ;  but  never  until  the  surgeon  is  satisfied  that  the  result- 


114  HYDROCARBON  PROTHESES 

ant  new  connective  tissue  thrown  out  has  reached  its  ultimate 
growth. 

The  harder  paraffines,  especially  those  injected  in  the  liquified 
state,  are  not  to  be  tolerated  for  the  reasons  given  with  the  pro- 
ceeding method  of  correction. 

Subseptal  Deficiency — Partial  and  Complete. — It  is  not  un- 
common to  find  a  marked  concavity  of  the  subseptum  in  noses 
that  have  sunken  in  by  reason  of  intranasal  disease  or  traumatism. 

This  concavity  when  partial  is  usually  most  marked  near  the 
lobule  but  in  the  complete  variety  the  upward  curve  may  be 
greatest  near  its  juncture  with  the  lip. 

Owing  to  the  usual  adhesions  formed  during  the  inflamma- 
tory period  causing  the  deformity  the  correction  of  this  defect 
is  quite  difficult.  As  a  rule  the  skin  of  the  entire  subseptum 
needs  to  be  dissected  away  from  the  underlying  structure 
before  it  will  permit  of  correction  by  the  injection  method. 

This  dissection  is  advocated  and  can  be  readily  done  from  one 
of  the  nostrils  at  a  point  just  beyond  the  union  of  skin  and  mu- 
cous membrane. 

The  dissection  under  such  method  can  be  made  more 
thoroughly  than  when  done  exteriorly  for  the  reason  that  the 
entire  field  is  laid  open  to  a  free  use  of  the  scalpel  leaving  no 
visible  cicatrix  externally.  The  dissection  may  be  followed  by 
the  immediate  injection  of  the  mixture  of  paraffine  and  vaseline 
as  already  referred  to,  used  cold,  or  the  area  is  injected  with 
normal  salt  solution  until  the  intranasal  wound  has  healed, 
which  usually  takes  place  in  about  five  days.  The  mucous 
membrane  in  such  instance  may  be  neatly  but  not  too  tightly 
sutured  with  No  i  silk.  If  the  operator  deems  it  advisable 
he  may  inject  the  salt  solution  again  on  the  third  day  to  pre- 


HYDROCARBON  PROTHESES  115 

vent  the  formation  of  such  adhesions  as  may  interfere  with 
the  ultimate  hydrocarbon  injection.  This  is  rarely  found  nec- 
essary. 

If  the  post-operative  inflammation  prove  mild,  then  the  adhe- 
sions will  not  be  as  tenacious,  in  which  case  the  surgeon  may 
wait  until  even  the  seventh  or  eighth  day  before  injecting  the 
paraffine  compound  to  be  sure  of  not  forcing  the  intranasal 
wound  apart  under  the  pressure  of  the  mass  injected. 

Never  should  so  large  a  quantity  of  the  mass  be  injected  as 
to  cause  blanching  of  the  narrow  strip  of  skin.  This  is  sure  to 
result  in  gangrene  of  some,  if  not  all,  of  the  skin  of  the  sub- 
septum — a  result  much  to  be  regretted  since  subsequent  cor- 
rection of  the  deformity  increased  by  the  contraction  of  the 
dermal  cicatrix  is  rendered  well-nigh  impossible  by  reason  of 
this  very  tissue. 

Hard  paraffine  injected  in  its  molten  state  is  never  borne  in 
this  part  of  the  human  economy.  It  is  usually  thrown  off  after 
a  few  days  of  very  painful  and  highly  inflammatory  symptoms, 
undoubtedly  explained  by  the  fact  that  the  circulation  of  the 
subseptum  is  principally  dependent  upon  the  delicate  branches 
of  the  two  small  septal  arteries  of  the  superior  coronary  and  a 
hard  ungiving  mass  would  readily  cause  their  obliteration. 

DEFORMITIES  ABOUT  THE  MOUTH 

LABIAL  DEFICIENCY 

Upper  and  Lower  Lip 

There  are  a  number  of  causes  creating  deficiencies  about  the 
labial  orifice.  The  same  causes  apply  naturally  to  both  lips 
whether  the  defect  be  unilateral,  bilateral  or  median.     Some  of 


ii6  HYDROCARBON  PROTHESES 

these  deformities  are  more  often  met  with  than  others,  as,  for 
instance,  a  median  deficiency  of  the  upper  lip  following  cicatri- 
cial contraction  due  to  a  harelip  operation  done  early  in  life  ;  in 
elderly  patients  a  partial  paralysis  is  found  to  affect  one-half 
the  upper  and  sometimes  a  part  of  the  lower  lip,  giving  to  the 
mouth  a  drooped  and  grinning  appearance. 

Other  causes  are  dental  defects,  abnormalities  of  the  alvelo- 
lar  processes,  traumatism  and  disease. 

In  those  conditions  where  loss  of  tissue  is  responsible  for  the 
defect,  as  in  the  extirpation  of  neoplasms,  ulcerative  disease 
etc.,  it  is  quite  likely  that  cheiloplasty  is  required  to  rebuild  the 
parts,  but  in  many  of  these  cases  splendid  results  may  be  ob- 
tained by  the  judicious  use  of  hydrocarbon  protheses  to  over- 
come the  usual  post-operative  oral  distortion.  It  is  understood 
that  such  injections  should  not  be  undertaken  until  the  wounds 
are  thoroughly  healed  and  the  cicatricial  union  fully  contracted. 
This  is  true  also  in  harelip  operations  undertaken  later  in  life. 

The  correction  of  labial  defects  coming  under  this  method  is 
not  at  all  difficult,  but  artistic  skill  and  judgment  are  as  neces- 
sary as  the  surgical  technic. 

The  lips  are  plentifully  supplied  with  blood-vessels  and  there- 
fore greater  care  in  injecting  a  foreign  mass  into  their  structure 
is  necessary,  furthermore  the  lips  cannot  be  placed  at  rest  for 
any  long  period  of  time,  so  that  the  mass  injected  can  never  be 
expected  to  be  kept  in  place  if  of  a  consistency  hard  enough  to 
permit  the  contraction  of  the  orbicularis  muscle  to  move  it 
about. 

From  the  very  fact  of  this  practically  constant  movement  of 
a  part  it  is  self-evident  such  hard  mass  could  not  be  retained  or 
held  in  position  for  any  length  of  time,  unless  the  mass  is  small 


HYDROCARBON  PROTHESES  117 

enough  not  to  be  affected  by  the  movement  and  under  such 
condition  the  correction  of  a  defect  as  desired  by  the  patient 
would  require  perhaps  months  to  accompUsh,  owing  to  the  very 
fact  that  only  drop-like  masses  may  be  deposited  under  the  skin 
in  perhaps  a  half  dozen  places  with  the  necessity  of  a  long  period 
of  rest  until  the  injections  have  been  replaced  by  the  new  tissue 
before  the  next  operation  could  be  undertaken. 

It  is  absolutely  absurd  to  think  of  injecting  a  lip  with  hard 
parafifine  liquified  by  heat  and  expect  to  obtain  a  satisfactory  re- 
sult. While  it  is  true  the  mass  is  mouldable  immediately  after 
its  introduction,  so  that  a  desired  shape  may  be  obtained,  it  does 
not  overcome  the  fact,  however,  that  the  mass  must  harden,  as 
it  will,  and  that,  while  a  part  of  it  is  broken  away,  as  it  were, 
from  the  mass  proper,  there  is  a  nuclear  contraction  as  the  hard- 
ening takes  place,  thus  overcoming  partly  the  moulded  form, 
furthermore,  the  movement  of  the  parts  here  tends  to  displace 
the  mass.  Unequal  muscular  contraction  breaks  up  not  only 
the  form  but  also  the  mass  itself,  during  all  of  which  time  it  is 
made  to  act  as  an  irritant  by  virtue  of  the  movement  of  the 
uneven  edges  of  the  parafifine  upon  the  adjacent  tissue. 

Furthermore,  the  presence  of  parafifine  and  the  resultant  mass 
of  new  and  hard  connective  tissue,  so  well  recognized  by  all  ex- 
perienced surgeons,  is  not  desirable  in  the  lip  structure  ;  it 
makes  the  lip  appear  bulkly  and  hard  and  anything  but  natural 

It  is  in  these  very  cases  that  the  injections  of  cold  sterile  white 
vaseline  is  indicated.  After  injection  the  mass  may  be  evenly 
and  satisfactorily  moulded  out,  the  mass  being  soft  and  readily 
pressed  into  shape  in  the  various  cells  of  areolar  tissue  without 
leaving  hard  and  uneven  lumps. 

The  movement  of  the  lip  is  not  then  a  source  of  danger  in, 


ii8  HYDROCARBON  PROTHESES 

displacing  the  mass,  since  the  acute  swelling  of  the  lip  tissue 
prevents  its  free  movement  for  several  days,  which  gives  the 
injected  mass  an  opportunity  to  establish  itself  and  find  its 
proper  place. 

Another  advantage  in  using  this  preparation  subcutaneously 
is  that  it  is  less  irritating  than  hard  paraffine,  permits  freer 
movement  and  creates  a  better  production  of  new  connective 
tissue. 

While  a  part  of  the  mass  may  be  absorbed  during  the  replace- 
ment period  the  lip  retains  its  normal  consistency,  and  if  the 
desired  contour  has  not  been  attained  a  subsequent  injection 
may  be  made  in  three  weeks'  time  without  interfering  in  any 
way  with  the  former  result. 

The  only  precaution,  aside  from  avoiding  the  injection  of 
blood  vessels,  is  to  keep  the  injection  from  the  prolabium  or 
vermihon  border.  The  latter  tissue  is  very  prone  to  fatty  de- 
generation or  to  yellowish  discoloration  when  such  a  foreign 
mass  has  been  introduced  into  or  near  its  structure. 

There  is  no  objection  in  injecting  the  lip,  upper  or  lower,  in 
several  places  as  the  cellular  network  about  the  mouth  is  suffi- 
ciently dense  to  prevent  the  escape  of  the  vaseline  injected  from 
the  adjacent  opening  if  the  distance  is  not  less  than  a  half  inch 
between  the  punctures. 

The  injections  may  be  made  from  above  downward  in  the 
upper  lip  and  vice  versa  in  the  lower.  They  should  be  begun 
at  the  outer  angle  working  toward  the  median  line. 

The  reaction  following  such  an  injection  is  usually  more  severe 
than  in  any  other  tissue  of  the  face  owing  to  the  great  number 
of  fine  blood  vessels,  but  the  swelling  is  readily  controlled  in 
two  or  three  days  by  cold  appHcations. 


HYDROCARBON  PROTHESES  119 

Aristol  collodion  dressings  over  each  wound  suffice  to  close 
the  punctures. 

In  the  median  variety  of  defect,  where  a  cicatricial  band 
separates  the  lip  into  halves,  it  may  be  found  necessary  to  do 
a  subcutaneous  dissection  before  a  suitable  injection  can  be 
done,  but  in  cases  of  long  standing  the  dividing  wall  is  exceed- 
ingly thin  and  the  thread-like  adhesions  below  are  quite  easily 
broken  up  by  the  force  of  the  injection.  The  later  product 
of  new  connective  tissue  will  tend  to  further  improve  the  con- 
tour. 

Naso-labial  Furrow — Unilateral  and  Bilateral. — This  condi- 
tion in  the  bilateral  form  is  exceedingly  common  in  adults  be- 
yond middle  age.  It  is  also  found  in  those  individuals  suffering 
from  inanition,  due  to  whatever  cause.  The  unilateral  form  is 
found  principally  in  patients  suffering  from  semifacial  paralysis 
in  which  the  tissue  lacking  the  proper  neurotic  supply  droops 
or  sags  down  causing  a  deep  furrow  to  appear  from  the  attach- 
ment of  the  alae  to  the  angle  of  the  mouth,  associated  more  or 
less  by  a  flattening  of  the  cheek  contour  of  that  side  of  the 
face. 

The  method  of  correction  advocated  by  the  author  varies  en- 
tirely from  the  technic  advanced  by  other  surgeons. 

The  usual  method  has  been  to  introduce  the  needle  of  the 
syringe  at  the  outer  or  lower  extremity  of  the  furrow  and 
from  one  of  such  punctures  to  inject  the  whole  line  of  depres- 
sion. 

While  this  seems  right  theoretically  the  method  does  not 
give  the  desired  result.  Owing  to  the  free  movement  of  the 
upper  lip  the  mass,  at  first  neatly  restoring  the  contour,  is 
crowded  upward  into  the  inferior  malar  region  and  very  often 


I20  HYDROCARBON  PROTHESES 

downward  toward  the  angle  of  the  mouth  where  it  settles  in  a 
hard  lump  which  is  not  only  obnoxious  to  the  sight  but  interferes 
with  the  proper  use  of  the  parts  concerned  in  mastication  and 
vocalization.  Invariably  the  operator  is  called  upon  to  remove 
the  disfigurement. 

It  can  be  readily  understood  that  hard  paraffine  itself,  in  such 
case,  would  prove  more  objectionable  than  a  softer  mass  which 
upon  early  discovery  could  be  moulded  or  massaged  into  better 
position  while  nothing  less  than  excision  would  prove  efficacious 
with  paraffine. 

As  with  the  lip  then  the  author  advocates  the  use  of  either 
the  cold  mixture  of  paraffine,  as  heretofore  described,  or  the 
cold  white  vaseHne  according  to  the  operator's  opinion  in  over- 
coming the  extent  of  the  fault.  For  all  ordinary  cases  white 
vaseline  alone  is  necessary. 

The  technic  of  injection  as  used  by  the  author  is  as  fol- 
lows :  — In  the  ordinary  case  when  the  furrow  is  not  too  pro- 
nounced one  sitting  only  is  required.  Two  needle  punctures 
are  made  above  the  upper  line  of  the  defect,  the  first  being  made 
about  one-half  inch  from  the  wing  of  the  nose  and  the  other 
about  one  inch  outward  and  downward. 

The  needle  is  pushed  downward  under  the  skin  until  its  open- 
ing corresponds  to  the  median  line  or  deepest  part  of  the  fur- 
row. Enough  cold  white  vaseline  is  injected  to  bring  the  de- 
pressed area  slightly  above  the  plane  of  the  skin  of  the  upper 
lip.  The  second  puncture  is  made  perpendicular  to  the  first 
and  the  injection  made  in  the  same  manner. 

With  the  tip  of  the  indicis  over  the  first  needle  opening  the 
mass  is  moulded  out  evenly  by  a  gentle  rocking  or  rubbing 
movement.     The  same  is  done  with  the  second  mass. 


HYDROCARBON  PROTHESES  121 

It  will  be  found  then,  that  the  two  masses  are  made  to  meet 
at  about  the  center  of  the  furrow,  leaving  a  slight  wall  of 
tissue  between  them.  This  wall  has  the  virtue  of  preventing 
the  falling  down  of  the  upper  mass,  at  the  same  time  divid- 
ing the  quantity  of  the  injected  mass  into  two,  and  lessening 
the  weight. 

If  the  condition  is  bilateral  both  sides  are  operated  on  at 
the  same  sitting.  If  subsequent  injections  are  needed  they  are 
done  three  weeks  later,  the  punctures  being  made  between  the 
former  first  and  second  punctures  and  the  second  and  outer  bor- 
der of  the  furrow.-  In  this  way  the  entire  site  is  filled  with  a 
series  of  injections. 

If  the  surgeon  desires  he  may  increase  the  number  of  these 
needle  punctures  at  the  first  sitting  making  them  nearer  to- 
gether in  that  event. 

It  will  be  found  necessary  in  some  cases  to  inject  the  cold 
mixture  of  vaseline  and  paraffine  into  the  furrow  directly  below 
the  wing  of  the  nose,  since  the  integument  at  that  point  re- 
quires a  mass  somewhat  harder  than  vaseline  to  force  and  hold 
it  up. 

The  rest  of  the  furrow  must,  however,  be  injected  with  vase- 
line alone,  for  the  reasons  already  given  in  parts  that  are  move- 
able. 

The  reaction  is  rarely  very  marked  and  subsides  in  about 
three  days. 

Gentle  massage  may  be  permitted  above  the  site  of  injection 
to  keep  the  mass  from  crawling  into  the  cheek.  This  is  done 
by  gently  stroking  the  skin  from  below  upward  toward  the  nose 
on  a  line  an  inch  above  the  original  depression. 

The  dressings  are  the  same  as  before  mentioned,  although 


122  HYDROCARBON  PROTHESES 

collodion  painted  over  the  needle  openings  is  most  serviceable 
after  having  sponged  off  the  sites  with  absorbent  cotton  dipped 
into  absolute  alchohol  to  remove  the  vaseline  that  may  have  ex- 
uded from  the  openings  during  the  moulding  out  process. 

Oral-Angular  Furrow. — These  furrows  occur  at  the  corners 
of  the  mouth,  running  downward  upon  the  anterior  chin.  Small 
as  these  defects  appear  they  are  found  difficult  of  obliteration, 
for  the  reason  that  the  tissues  are  more  or  less  under  constant 
movement  during  the  waking  hours.  Repeated  injections,  each 
of  small  quantity,  are  necessary.  Hard  paraffine  is  contraindi- 
cated. 

The  injections  are  made  from  above  the  defect  downward  at 
right  angles  to  the  defect. 

It  will  be  found  difficult  to  keep  the  mass  from  being  expelled 
on  account  of  the  movement,  there  being  more  or  less  oozing 
from  the  puncture,  but  if  the  openings  can  be  controlled  for  at 
least  twenty-four  hours  this  danger  may  be  overcome  to  a  great 
extent. 

Ethyl  chloride  may  be  sprayed  over  the  part  immediately  the 
needle  is  withdrawn  to  set  the  mass  and  followed  with  a  drop 
of  collodion.  The  patient  is  advised  to  keep  the  mouth  as  im- 
movable as  possible  for  the  rest  of  the  day. 

The  reaction  is  never  severe,  and  is  easily  controlled  by  cold 
applications.  If,  after  one  week,  there  is  shown  a  tendency  to 
sagging  of  the  mass,  it  should  be  gently  massaged  upward  with 
the  finger  several  times  during  the  day  for  at  least  two  weeks ; 
this  will  keep  it  in  place,  and  allow  nature  to  replace  it  with  new 
connective  tissue  when  desired. 


HYDROCARBON  PROTHESES  123 

DEFORMITIES  ABOUT  THE  CHEEKS 

DEFICIENCY  OF  CHEEK 

Total  and  Partial 

A  total  lack  of  proper  contour  of  the  cheek,  generally  termed 
flattening,  may  be  due  to  hereditary  causes,  but  is  generally  de- 
pendent upon  a  cachexia  due  to  a  general  disease,  or  fatty  de- 
generation of  the  muscular  structure  of  the  cheeks,  as  found  in 
those  beyond  middle  age. 

A  partial  deficiency  of  the  cheek  or  cheeks  is  usually  heredi- 
tary but  may  be  dependent  upon  digestive  disorders  or  other 
causes  of  malnutrition. 

This  class  of  deformity  is  found  more  often  in  women  than 
men.     It  is  usually  bilateral. 

Unilateral  cheek  deficiency,  whether  partial  or  total  may  be 
congenital  but  is  often  the  result  of  a  local  paralysis  causing 
hemiatrophy.  Traumatisms  early  in  life  or  during  birth  and 
amputation  of  the  inferior  maxillary  are  other  causes. 

This  class  of  deformity  is  quite  readily  corrected  by  subcu- 
taneous injection,  in  fact  it  is  the  only  known  method  of  merit, 
superseding  the  former  resort  to  partial  correction  by  massage 
or  artificial  and  temporary  correction  by  the  wearing  of  plum- 
pers in  the  buccal  cavity. 

The  method  of  procedure  is  the  same  in  all  cases,  the  num- 
ber of  injections  and  quantity  varying,  of  course,  with  the  ex- 
tent of  the  defect. 

As  with  the  rebuilding  of  the  contour  of  the  lips  so  with  the 
cheeks,  which  must  of  necessity  be  mobile  and  flexible,  the  in- 
jection of  hard  paraffine  is  out  of  the  question.     The  author 


124  HYDROCARBON  PROTHESES 

has  observed  a  number  of  such  cases  and  is  free  to  say  that  in 
each  case  the  result  was  not  only  abnormal  in  appearance,  but  a 
source  of  great  annoyance  to  the  patient. 

What  is  worse,  is  that  the  parafhne  once  injected,  can  never 
be  removed  except  in  places  where  an  actual  encystment  has 
taken  place,  in  which  case  the  hard  mass  may  be  removed 
through  a  small  incision  made  directly  over  the  mass  and  intro- 
ducing a  grooved  director  into  the  opening  then  by  the  rotation, 
or  to  and  fro  movement  of  which,  combined  with  digital  pressure 
the  cyst  is  evacuated.  Once  the  mass  is  replaced  by  a  network 
of  connective  tissue  it  could  not  be  removed  except  by  an  ex- 
tensive dissection  and  extirpation  which  leaves  behind  it  cicatrices 
far  worse  than  the  appearance  of  the  parts  before  operation. 

The  author  injects  cold  sterile  white  vaseline,  below  the  skin 
here  and  there  about  the  cheek  at  the  sites  of  deepest  defi- 
ciency. 

These  injections  maybe  made  under  ethyl  chloride  anesthesia. 

Each  injection  is  carried  to  the  extent  of  causing  a  lump  be- 
low the  skin,  the  quantity  being  judged  from  a  thorough  experi- 
ence with  similar  cases. 

After  the  injections  have  all  been  done,  the  thumb  of  the  right 
hand  is  passed  into  the  mouth  against  the  buccal  mucous  mem- 
brane of  the  left  cheek  and  the  index  finger  over  it  externally 
or  on  the  skin  surface.  For  the  right  cheek  the  index  finger 
instead  of  the  thumb  is  placed  in  the  mouth.  The  mass  or 
lumps  are  now  gently  pressed  into  the  desired  shape  and  thick- 
ness by  the  aid  of  these  two  fingers.  A  few  drops  of  the  mass 
may  be  forced  out  of  the  needle  holes  under  this  procedure,  but 
this  is  of  no  consequence  when  it  is  considered  that  from  one  to 
two  ounces  may  have  been  injected  into  each  cheek. 


HYDROCARBON  PROTHESES  125 

This  gliding  form  of  massage  should  be  continued  until  the 
entire  cheek  presents  an  even  and  rounded  out  appearance. 

It  will  be  found,  in  the  majority  of  cases,  that  the  integument 
of  the  cheeks  about  the  region  of  the  inferior  border  of  the 
zygomatic  process  is  rather  firmly  adherent  and  that  a  subsequent 
injection  will  be  necessary  to  elevate  the  check  at  that  point. 

Injections  over  the  malar  bone  are  prone  to  cause  severe  re- 
action leaving  a  puffed  appearance  just  below  the  eyelids.  This 
may  be  more  or  less  permanent  and  is  very  undesirable.  It 
should  be  avoided  by  injecting  very  small  quantities  at  that  site. 
It  is  always  safer  to  add  a  little  subsequently. 

The  reaction,  generally,  is  not  severe  and  is  readily  controlled 
by  cold  applications,  yet  the  author  has  experienced  considerable 
swelling  and  tenderness  in  two  cases  of  total  cheek  deficiency 
corrections  which  lasted  for  several  weeks  after  the  operation, 
giving  excellent  result  eventually  however.  Such  symptoms 
are  dependent  upon  circulatory  interference,  but  resolution 
should  take  place  without  untoward  results  with  judicious  treat- 
ment, unless  the  operator  has  been  negligent  by  injecting  one 
or  more  blood  vessels,  in  which  case  the  resultant  thrombosis 
may  cause  breaking  down  of  the  subcutaneous  tissue,  abscess, 
evacuation  of  the  mass  and  possibly  death  in  part  of  the  integu- 
ment. The  precautions  referred  to  in  avoiding  any  such  possi- 
bility have  been  fully  given  heretofore. 

Never  should  the  operator  hyperinject  the  cheeks,  even  if  the 
patient  insists  upon  looking  like  a  puffed  ball.  He  should  be 
satisfied  with  a  normal  contour  and  truthfully  assure  the  patient 
such  hyperinjected  contour  could  not  be  retained  owing  to  the 
weight  and  dropping  down  of  the  mass  before  nature  could 
properly  replace  it  by  organized  tissue. 


126  HYDROCARBON  PROTHESES 

Subsequent  injections  may  be  made  about  three  weeks  after 
the  first  sitting. 

With  nervous  and  hypercritical  patients  the  surgeon  may 
elect  to  give  the  patient  a  number  of  sittings,  injecting  only 
small  quantities  at  two  or  three  places  each  time.  This  in  the 
majority  of  cases  will  give  better  results  than  when  an  entire 
cheek  is  injected,  for  the  reason  that  the  larger  mass  is  likely 
to  be  displaced  by  the  unconscious  act  of  the  patient  in  sleeping 
on  one  or  both  of  the  rebuilt  cheeks  or  the  willful  massage  to 
improve  the  handiwork  of  the  surgeon  in  their  own  belief. 

Massage  of  the  cheeks  after  the  replacement  period  is  not  to 
be  tolerated.  It  tends  to  create  hyperplasia  by  circulatory 
stimulation. 

It  is  not  unusual  to  have  the  patient  tell  you  that  for  weeks 
after  the  replacement  period  the  cheeks  are  swollen  consider- 
ably in  the  morning  upon  arising,  gomg  down  gradually  during 
the  day. 

This  is  due  to  the  spongy  or  loose  character  of  the  new  tissue 
caused  to  be  formed  by  the  foreign  mass  which  gradually  takes 
on  a  harder  and  more  compact  form. 

The  post-operative  dressing  will  be  either  adhesive  isinglass 
plaster  or  collodion.  With  the  former,  moist  applications  dur- 
ing the  stage  of  reaction  are  not  permissible. 

DEFORMITIES  ABOUT  THE  ORBIT 

DEFICIENCY  OF  LID  CONTOUR 

Upper  and  Lower  Lids — Unilateral  and  Bilateral. — The  lack 
of  contour  in  the  eyelids  is  not  as  frequently  met  with  as  redun- 
dancy of  their  integumentary  structure ;  there  are  cases,  however, 


HYDROCARBON  PROTHESES  127 

where  the  eyes  seem  to  He  deep  in  their  sockets  owing  to  a  sink- 
ing in  or  a  collapse  of  the  surrounding  lids. 

This  condition  is  often  found  to  be  hereditary,  in  other  cases 
it  is  the  result  of  malnutrition,  a  peculiar  lack  of  adipose  tissue 
about  the  orbit  for  no  known  reason,  or  fatty  degeneration  in 
past  middle  hfe. 

The  fault  is  usually  bilateral.  In  rare  instances  trauma  about 
the  orbital  borders  may  result  in  lack  of  nutrition.  Such  cases 
are  usually  unilateral  and  the  upper  lid  is  affected  in  the  major- 
ity of  cases. 

The  correction  of  these  defects  is  found  to  be  rather  difficult 
owing  to  the  thickness  of  the  tissue  under  consideration. 

The  use  of  hard  paraffine  plays  havoc  with  eyelid  tissue,  ren- 
dering it  hard,  immobile  and  causing  a  hyperplasia  of  the  new 
connective  tissue  formed  thereby,  as  well  as  the  peculiar  yellow- 
ish pigmentary  spots  of  irregular  form  resembling  on  casual  in- 
spection xanthalasma.  This  discoloration  has  been  fully  de- 
scribed earlier  in  the  work. 

The  author  has  had  occasion  to  remove  these  hard  irregular 
masses  investing  the  lower  lid  in  several  cases  where  paraffine 
had  been  injected,  also  two  cases  in  which  the  pigmentary  dis- 
coloration involved  both  upper  and  lower  lids  associated  with 
the  same  hard  fibrous  masses.  Excision  under  local  anesthesia 
and  silk  suture  was  the  method  of  correction  employed. 

From  an  experience  of  twenty-two  cases  the  author  believes 
these  conditions  most  amenable  for  correction  by  the  injection 
of  sterile  oils  in  preference  to  any  other  substance.  Even  white 
vaseline  does  not  here  seem  to  answer  the  purpose,  owing  to  its 
stimulating  property  of  causing  the  resultant  growth  of  con- 
nective tissue. 


128  HYDROCARBON  PROTHESES 

While  vaseline  injected  in  the  lids  causes  less  of  this  new- 
tissue  to  be  formed,  such  tissue  is  never  of  the  consistency  re- 
quired.    This  is  especially  true  of  the  upper  lids. 

The  oil  injected,  sterlized  sperm  oil  being  employed  by  the 
writer,  is  prone  to  absorption  of  more  or  less  degree,  but  the  re- 
sult is  gratifying  and  lasts  from  six  months  to  one  year,  leaving 
no  untoward  effect. 

If  the  absorption  has  been  sufficient  to  leave  the  parts  as  be- 
fore the  operation,  a  subsequent  injection  of  the  same  character 
may  be  undertaken  six  months  from  the  time  of  the  first  or  even 
later  as  the  patient  may  choose. 

The  tissue  of  the  eyelid  is  prone  to  swell  immediately  the  oil 
is  injected  and  this  swelling  is  entirely  out  of  proportion  to  the 
quantity  introduced.  This  oedema,  due  to  a  retardation  by  pres- 
sure of  the  blood  supply,  is  very  misleading,  the  operator  believ- 
ing the  parts  overinjected.  A  screw  drop  syringe  is  therefore 
absolutely  required. 

A  fine  hypodermic  needle  is  used  and  after  a  few  drops  of  the 
foreign  matter  have  been  injected,  the  lid  should  be  massaged 
gently  with  the  tip  of  the  indicis,  employing  the  circular  move- 
ment. 

The  injection  should  be  made  at  the  outer  end  of  the  lid 
about  one-fourth  inch  above  or  below  the  canthus  for  upper  or 
lower  lid  respectively. 

The  needle,  slightly  dulled,  should  be  long  enough  to  reach 
the  full  length  of  the  part  to  be  injected.  Its  course  can  be 
readily  seen  under  the  thin,  overlying  skin. 

As  the  injection  progresses  slowly  and  evenly  the  needle  is 
withdrawn. 

A  second  puncture  or  injection  should  not  be  made  at  one 


HYDROCARBON  PROTHESES  129 

sitting  ;  if  the  parts  are  under-injected  the  operation  is  repeated 
as  soon  as  the  swelhng  of  the  lid  has  subsided,  which  is  about 
the  end  of  the  fourth  or  fifth  day. 

The  reaction,  apart  from  the  oedema,  is  very  Uttle,  although 
there  may  be  more  or  less  discoloration  of  the  parts  as  the  re- 
sult of  the  obstruction  offered  the  blood  vessels. 

This  is  always  an  alarming  symptom  to  the  patient,  but  passes 
away  completely  in  the  usual  manner  in  several  days. 

The  post-operative  dressings  may  be  collodion  or  silk  pro- 
tective. 

Cold  or  hot  applications,  as  may  be  best  borne  by  the  patient, 
can  be  used  ;  they  tend  to  reduce  the  puffing  and  lessen  the  ec- 
chymosis.  The  patient  should  be  instructed  to  lie  with  the  head 
higher  than  usual  for  the  first  two  nights  to  retard  the  oedema. 

Furrow  about  Canthus — Unilateral  and  Bilateral. — This  con- 
dition is  commonly  called  "  Crow's  Feet,"  and  is,  in  the  major- 
ity of  cases,  due  to  advancing  age,  but  is  acquired  by  habitually 
contracting  the  eyelids,  as  in  laughing  or  grimacing.  It  is  par- 
ticularly noticeable  in  persons  employed  in  the  drama. 

The  defect  is  usually  bilateral,  but  may  exist  at  one  side  only 
in  rare  cases. 

The  correction  is  easily  accomplished  by  this  method  of  sub- 
cutaneous injection,  although  a  reduction  of  the  furrow  alone 
does  not  suffice,  leaving  a  lump  or  elevation  at  the  site.  The 
author  shades  off  the  injection,  as  it  were,  making  the  site 
somewhat  cone-like,  the  apex  being  at  the  canthus  and  the 
base  outward  toward  the  hair-line  of   the  temporal  region. 

Sterile  oil  should  be  injected  near  the  canthus  where  the 
overlying  integument  is  delicate.  One  such  injection,  covering 
an   area  of  the  diameter  of  half  to  three-fourths  of  an  inch, 


I30  HYDROCARBON  PROTHESES 

should  be  made  and  thus  backed  up  or  built  outward  with  two 
or  three  injections  of  the  white  vaseline,  as  described  under 
temporal  muscular  deficiency. 

The  hypodermic  needle  should  be  used  near  the  canthus,  and 
the  regular  one  over  or  about  the  temple. 

The  reaction  near  the  canthus  is  similar  to  that  with  lid  in- 
jections. The  same  post-operative  treatment  as  with  the  lids 
should  be  employed. 

Deficiency  of  the  Ocular  Stump. — It  frequently  happens  that 
by  reason  of  extensive  inflammatory  disease  and  adjacent  adhe- 
sions of  the  eye,  a  greater  part  of  the  globe  must  be  excised 
than  in  the  usual  case,  whether  the  operation  be  an  ordinary 
excision,  the  Mules'  evisceration  or  the  Frost  modification  of 
the  latter. 

In  such  event  the  granular  button  or  the  stump  made  of 
Tenon's  capsule  is  too  small  to  permit  of  the  placing  and  re- 
tention of  the  artificial  eye.  In  other  instances  the  stump  is  so 
contracted  that  while  the  artificial  eye  is  retained  it  must  of  ne- 
cessity be  allowed  to  rest  deep  in  the  socket,  destroying  the  en- 
tire contour  of  the  orbit.  Again  in  the  enucleation  operation 
so  little  of  Tenon's  capsule  engages  the  artificial  eye  that  move- 
ment is  entirely  destroyed,  particularly  when  the  Mules'  glass 
globe  has  not  been  introduced. 

Excellent  results  may  be  obtained  in  some  of  these  cases, 
others  are  not  amenable  to  the  injection  method  because  of  a 
lack  of  sufficient  stump  to  inject  and  the  danger  of  injecting 
through  the  posterior  wall  of  the  capsule,  the  mass  in  part  es- 
caping into  the  orbital  apex  where  it  is  liable  to  impinge  suffi- 
ciently upon  the  remains  of  the  optic  nerve  to  cause  sympathetic 
inflammation  of  the  normal  eye.     A  condition  at  once  not  easily 


H\'DROCARBON  PROTHESES  131 

corrected,  proving  dangerous  to  the  sight  of  the  healthy  eye 
and  possibly  producing  a  fatal  termination. 

It  is  with  the  use  of  parafifine,  liquified  by  heat  and  injected 
in  this  state,  that  such  fatal  cases  as  have  been  placed  on  record 
have  been  operated.  The  liquid  mass  under  pressure  forced 
into  a  soft  pultaceous  mass  cannot  be  easily  controlled,  if  at  all, 
and  accidents  here  are  of  more  serious  import  than  in  any  other 
part  of  the  human  anatomy,  apart  from  the  direct  injection  of  a 
facial  artery  of  sufficient  size  to  produce  an  alarming  embolism 
and  death. 

The  author  cannot  speak  too  forcibly  against  such  irrational 
procedure.  Other  surgeons  are  beginning  to  realize  the  danger 
of  the  use  of  hard  paraffine  injections  near  the  eye. 

The  proper  and  safe  method  of  improving  the  stump  is  to  in- 
troduce into  it,  under  local  eucaine  or  cocaine  anesthesia,  small 
masses  of  the  mixture  of  vaseline  and  paraffine  in  cold  state. 
These  injections  into  the  stump  and  mucous  membrane  should 
be  done  several  weeks  apart,  always  keeping  a  respectful  dis- 
tance from  the  remains  of  the  optic  nerve. 

The  injections  should  be  begun  as  near  to  the  surface  as  pos- 
sible without  breaking  down  the  tissue  by  necrosis,  keeping  in 
mind  that  one  or  two  of  such  successfully  introduced  masses 
will  do  much  toward  supporting  the  artificial  eye. 

If  necessary  the  mucous  membrane  back  of  the  palpebral  rim 
can  be  injected  in  like  manner  to  give  firmer  hold  to  the  eye 
and  at  the  same  time  give  support  to  the  usually  depressed  and 
atrophied  lids. 

Wet  dressings  are  applied  to  allay  the  reactive  inflammation 
which  should  be  proportionate  in  severity  to  the  amount  of  the 
mass  injected. 


132  HYDROCARBON  PROTHESES 

In  three  cases  operated  upon  by  the  author  excellent  results 
were  attained  and  no  untoward  results  had  been  experienced 
two  years  after  injection, 

DEFORMITIES  ABOUT  THE  CHIN 
Anterior  and  Lateral  Deficiencies 

An  anterior  lack  of  contour  of  the  chin  is  generally  regarded 
as  of  the  receding  type.  With  this  is  usually  found  a  bilateral 
lack  of  form,  especially  in  men.  With  a  generally  well-formed 
face  such  a  chin  gives  it  a  weak  and  ofttimes  a  degenerate  ap- 
pearance. In  women  a  deficient  chin  is  not  as  noticeable,  be- 
cause of  the  smallness  of  the  face  in  general  and  the  predomi- 
nation of  the  oval  type. 

The  lack  of  prominence  about  the  chin  may  be  anterior  only, 
the  broadness  being  sufficient,  due  to  a  lack  of  development  of 
the  mental  process,  or  it  may  be  deficient  laterally  with  a  pro- 
nounced mental  prominence,  giving  it  a  sharp,  protruding  or 
pointed  appearance,  or  the  lack  of  form  is  combined  as  is  com- 
monly the  case. 

Such  chins  may  be  made  to  appear  normal,  and  even  ideal, 
by  the  subcutaneous  injection  method.  The  type  of  chin  most 
favored  by  American  men  is  the  square  angular,  now  so  plenti- 
fully seen  in  pen  and  ink  illustrations. 

The  tissue  of  the  chin  lends  itself  readily  to  the  building-up 
process.  Almost  any  form  may  be  attained  by  the  judicious 
employment  of  the  method  under  consideration. 

While  it  is  true  excellent  results  may  be  obtained  with  hard 
paraffine,  used  in  liquified  form,  it  can  often  be  shown,  however, 
that  the  paraffine  injected   under  pressure  will  run  down  in 


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HYDROCARBON  PROTHESES  133 

narrow,  pencil-like  streams  underneath  the  chin  and  skin  of 
the  anterior  aspect  of  the  neck,  where  they  may  be  felt  after- 
wards as  hard  oval  cysts  or  of  elongated  form.  This  is  not 
possible  when  the  cold  mixture  of  vasehne  and  paraffine  is  used, 
since  the  position  of  the  mass  can  be  easily  followed  with  the 
eye  or  felt  with  the  fingers. 

The  injections  should  be  made  from  either  angle  at  the  first 
sitting.  Enough  of  the  mass  should  be  introduced  to  leave  a 
ridge-like  formation  across  the  anterior  chin,  varying  in  thick- 
ness according  to  the  shape  of  the  chin  previous  to  operation 
and  the  form  desired. 

It  is  not  well  in  chins  of  very  deficient  type  to  attempt  to 
make  the  anterior  contour  as  it  should  be  in  the  first  sitting. 
Too  much  pressure  would  be  required,  and  unless  the  skin  was 
freely  movable  considerable  reactive  inflammation  would  result, 
with  possible  necrosis  of  the  skin  in  part  and  consequent  expul- 
sion of  the  injected  mass. 

The  anterior  line  of  such  chins  should  be  rebuilt  in  several 
sittings,  always  waiting  for  the  parts  to  become  normal  in  ap- 
pearance and  sensitiveness. 

This  method  helps  to  stretch  the  skin,  allowing  of  further 
injections  and  the  introductions  of  a  greater  quantity  than 
could  be  introduced  at  one  time  only. 

The  author  advocates  making  two  or  three  sittings  of  the 
anterior  restoration  of  contour  and  two  for  each  angle. 

The  angles  of  the  chin  are  injected  at  a  point  about  midway 
between  the  mental  process  and  beginning  of  the  external 
oblique  line.  The  mass  is  injected  as  near  the  inferior  ridge 
as  possible,  and  somewhat  above  the  attachment  of  the  platysma 
myoides  muscle. 


134  HYDROCARBON  PROTHESES 

Only  one  needle  insertion  is  made  at  each  angle,  and  the 
mass  is  injected  until  a  round  elevated  tumor  is  attained,  which 
is  pinched  or  squeezed  with  the  fingers  into  the  desired  angular 
form,  one  finger  being  placed  over  the  needle  opening  to  avoid 
squeezing  the  mass  out. 

It  can  be  readily  seen  that  with  this  putty-like  mass  much 
better  results  than  with  the  comparatively  soft  vaseline  could  be 
obtained  while  with  the  liquified  parafifine  the  operator  would  be 
at  a  loss  to  know  just  what  had  been  accomplished  until  the  mass 
had  become  fairly  solidified  and  then  often  finding  the  semi- 
solid mass,  which  required  rapid  moulding  to  give  it  the  desired 
shape  before  it  would  become  hard  and  unmanageable,  in  a  dif- 
ferent position  and  much  more  distributed  than  he  had  expected. 

For  the  latter  reason  repeated  small  injections  have  been  ad- 
vised, but  the  author  believes  oft  repeated  injections  of  paraffine 
in  a  small  area  are  prone  to  set  up  considerable  disturbance  and 
that  the  resultant  tissue  replacement  is  interfered  with.  Fur- 
thermore the  injected  mass  would  eventually  be  in  grape-bunch 
like  form  and  in  that  condition  not  as  manageable  or  inducive  to 
the  establishment  of  contour  angulation  such  as  is  required  in 
the  chin.  The  final  appearance  of  chins  thus  rebuilt  is  heavy 
and  rounded,  lacking  the  concavity  above  the  inferior  prom- 
inence along  the  anterior  line  as  well  as  the  angulation  laterally 

With  the  cold  mixture  advised  a  considerable  mass  may  be 
injected  at  one  sitting  which  is  easily  moulded  into  form  and 
which  retains  that  form  unless  the  reactive  inflammation  is 
severe.  This  should  not  follow  unless  actual  hyperinjection  has 
been  done  or  an  unclean  product  has  set  up  an  infective  cellulitis. 

When  the  chin  is  uncommonly  peaked,  or  small,  it  may  be 
found  necessary  to  inject  both  sides  of  the  chin  beyond  the  angle 


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HYDROCARBON  PROTHESES  135 

and  in  an  upward  direction  slightly  below  and  following  the  ex- 
ternal oblique  line. 

Such  deficiency  may  be  found  decidedly  unilateral  as  a  result 
of  lack  of  development  of  one-half  of  the  lower  maxillary  bone, 
a  resection  of  either  maxilla  for  whatever  cause,  imperfect  union 
following  fracture  or  disease  of  the  bone  early  in  life. 

In  such  cases  the  lateral  deficiency  must  be  first  restored, 
using  the  same  method,  before  the  chin  proper  can  be  built  up. 
Ofttimes  the  lower  cheek  of  the  affected  side  must  also  be  in- 
jected. This  should  be  done  after  the  site  overlying  the  former 
body  of  the  maxilla  of  the  affected  side  has  been  rebuilt.  The 
cheek  should  then  be  built  out  above  this  hard  linear  mass  by 
the  injection  of  cold  white  vaseline  as  heretofore  referred  to. 

The  following  illustrations  show  a  chin  deficient  anteriorly 
and  laterally  before  and  the  result  after  correction. 

The  post-operative  treatment  should  be  collodion  dressing 
followed  by  cold  antiseptic  applications  for  at  least  two  days. 
The  latter  ameliorates  the  inflammation  and  helps  to  retain  the 
moulded  shape  of  the  mass.  Subsequent  sittings  may  be  made 
one  a  week  or  ten  days  apart. 

DEFORMITIES  ABOUT  THE  EAR 

Pro-auricular  Deficiency — Unilateral  and  Bilateral. — A  deep 
furrow  in  front  of  the  ear  may  be  found  unilateral  in  hemiatrophy 
of  the  face,  but  the  condition  is  usually  a  bilateral  one  due  to 
malnutrition  or  the  fatty  degeneration  of  past  middle  age.  In 
the  latter  case  the  depression  is  accompanied  by  a  redundancy 
and  wrinkling  of  the  skin. 

Owing  to  the  close  proximity  of  the  large  temporal  vessels  a 


136  HYDROCARBON  PROTHESES 

hard  mass  should  never  be  injected  subcutaneously  for  the  re- 
Hef  of  this  condition.  Even  the  mixture  of  vaseline  and  paraf- 
fine  has  caused  considerable  reaction  when  injected  to  overlie 
these  vessels. 

The  author  advises  the  injection  of  white  sterile  vaseline  or 
sperm  oil  for  this  form  of  correction.  It  should  be  carefully  in- 
jected since  the  vessels  lie  close  to  the  skin  with  the  anterior 
auricular  crossing  transversely  about  the  center  of  the  furrow. 

Every  precaution  should  be  taken,  one  injection  only  being 
made  from  below  upward  at  each  sitting  if  more  than  one  is 
necessary  and  then  only  after  the  needle  has  been  unscrewed 
from  the  syringe  to  make  sure  vessel  bleeding  does  not  follow 
the  puncture. 

The  reaction  is  usually  severe  with  considerable  oedema  and 
ecchymosis. 

The  resultant  tissue  formation  likewise  is  active  and  hyper- 
plasia at  this  site  is  not  uncommon,  especially  if  the  mixture  or 
hard  paraffine  has  been  employed. 

A  cellulitis  following  such  an  injection  is  exceedingly  trouble- 
some, the  injected  mass  being  thrown  off  usually  at  the  base  of 
the  furrow,  which  is  followed  by  a  low  type  of  inflammation 
with  a  protracted  oozing  of  serous  exudate.  Should  such  a 
case  come  under  the  care  of  the  surgeon,  thorough  cleansing 
of  the  affected  site  under  scrupulous  antisepsis  should  be  done 
at  once,  and  wet  antiseptic  dressings  be  applied  daily  until  the 
wound  is  entirely  healed. 

A  plastic  skin  operation  must  be  done  in  most  of  these  cases 
to  overcome  the  ragged  cicatrix  formed  upon  healing  of  the 
wound.  This  should  never  be  undertaken  until  the  wound  has 
been  healed  for  several  weeks  at  least. 


HYDROCARBON  PROTHESES  137 

After  the  injection  of  the  parts  cold  antiseptic  dressings 
should  be  applied  at  once,  and  kept  up  until  every  sign  of  re- 
active inflammation  has  subsided.  At  no  time  should  the  sub- 
sequent injection  be  undertaken  before  a  month  has  elapsed 
from  the  time  of  the  former  operation. 

Post-auricular  Deficiency. — This  defect  is  invariable  unilate- 
ral, and  then  the  result  of  a  mastoid  operation. 

The  skin  about  the  depressed  site  will  be  found  to  be  more 
or  less  firmly  adherent,  necessitating  subcutaneous  dissection 
before  an  injection  for  correction  can  be  undertaken. 

In  this  case  the  cold  mixture  of  vaseline  and  paraffine  is  in- 
dicated since  the  softer  products  will  hardly  suffice  to  elevate 
the  tense  skin.  If  the  former  surgical  operation  has  been  done 
some  time  previous  to  the  required  injection  the  parts  may  at 
one  or  two  sittings  be  restored  to  a  fairly  normal  contour,  de- 
pending entirely  upon  the  amovmt  of  ungiving  scar  tissue  at 
the  site.  If  the  parts  are  tender  and  not  reduced  to  normal, 
the  injections  should  be  made  frequently,  about  ten  days  apart, 
injecting  a  small  mass  across  and  through  the  subcutaneous  scar 
attachment  at  each  sitting. 

The  reactions  following  such  injections  help  to  tease  the  scar 
away  from  the  bony  tissue,  but  should  not  be  sufficient  to  cause 
extensive  inflammation. 

The  same  mode  of  post-operative  treatment  as  has  been  given 
with  pro-auricular  corrections  should  be  followed. 


DEFORMITIES  ABOUT  THE  SHOULDERS 

Deficiencies  about  the  base  of  the  neck  and  the  shoulders  are 
very  commonly  found  in  women.  These  defects  are  usually  bi- 
lateral, except  in  rare  cases.  The  much  desired  contour  is 
readily  restored  by  the  subcutaneous  injection  method,  and 
since  the  technic  for  one  part  is  the  same  as  for  the  whole 
there  is  no  need  to  dilate  specifically  upon  the  treatment  of 
each  part. 

The  author  advocates  the  injection  of  cold  sterile  white  vase- 
line only,  for  the  restoration  of  the  contour  about  the  neck,  an- 
terior and  posterior  shoulder  and  the  mamnse,  except  in  the 
unilateral  correction  of  a  flattening  of  the  breast  following  am- 
putation for  the  removal  of  neoplasms,  when  the  mixture  of 
white  vaseline  and  paraffine  should  be  used,  owing  to  the  tense- 
ness of  the  skin  following  the  excision  of  a  large  part  of  the 
integument  covering  the  diseased  gland. 

In  the  restoration  of  the  contour  about  the  neck  and  shoul- 
ders it  is  well  for  the  surgeon  to  familiarize  himself  thoroughly 
with  the  superficial  veins  of  the  parts,  since  the  vessels  here  are 
larger,  and  the  introduction  of  foreign  matter  into  them  is  lia- 
ble to  lead  to  serious  and  even  fatal  results. 

The  injections  should  never  be  made  until  the  operator  has 
assured  himself  of  the  fact  that  a  vessel  has  not  been  entered 
into,  and  then  only  should  a  small  quantity  of  the  mass,  i.  e., 
about  two  or  three  drams,  be  injected  at  one  point. 


HYDROCARBON  PROTHESES  139 

The  easiest  mode  of  introducing  the  needle  is  to  pinch  up  the 
skin  between  the  fingers  of  one  hand  introducing  the  needle  into 
the  fold  thus  raised.  As  the  mass  is  injected  the  skin  should  be 
raised  by  aid  of  the  needle  so  as  to  allow  all  the  immediate  room 
possible  for  its  reception. 

The  mass  injected  is  at  once  moulded  down  flat  with  the  thumb 
or  forefinger. 

A  number  of  such  injections  may  be  made  at  both  sides  at 
the  on'  sitting.  The  ethyl  chloride  spray  may  be  employed 
to  render  the  parts  less  painful.  At  no  time  should  the  entire 
shoulders  be  filled  at  one  sitting  for  fear  that  the  reaction  may 
be  severe  or  that  for  any  unforseen  cause  infection  results  which 
would  in  such  instance  be  indeed  difficult  of  treatment,  event- 
ually leaving  the  parts  scarred  and  unsightly. 

Nor  should  the  mass  be  injected  intracutaneously,  a  fault 
sometimes  observed  about  the  base  fine  of  the  neck  anteriorly 
and  laterally  where  the  operator  has  been  timid  in  avoiding  the  ex- 
terior and  anterior  jugular  veins.  Such  injections  invariably  re- 
sult in  abscess  or  when  not  extensive  enough  to  cause  necrosis 
the  skin  assumes  a  more  or  less  permanent  red  or  yellow  discol- 
oration over  the  site  so  injected. 

The  treatment  for  the  partial  or  total  removal  of  such  spots 
has  been  referred  to. 

In  the  average  case  of  contour  restoration  of  the  shoulders 
about  eight  sittings  are  required,  two  sittings  being  given  each 
week  and  as  many  injections  made  as  is  deemed  necessary  or  ad- 
visable at  each. 

All  the  precautions  of  technic  heretofore  given  should  be  em- 
ployed. The  reaction  following  such  injections  is  never  severe 
and  Uttle  or  no  treatment  is  necessary. 


I40  HYDROCARBON  PROTHESES 

The  needle  openings  are  covered  with  aristol-collodion  or  the 
isinglass  adhesive  plaster. 

At  the  end  of  six  months  or  more  after  the  injected  mat- 
ter has  been  quite  thoroughly  replaced  with  new  connective 
tissue  it  is  often  found  necessary  to  inject  small  quantities  here 
and  there  about  the  shoulders  owing  to  the  contraction  of  the 
new  tissue  and  its  ultimate  fixed  disposition  about  the  parts 
more  than  to  the  absorption  of  the  mass  injected. 

Furthermore  a  certain  amount  of  oedema  or  swelling  follows 
the  injection  of  any  foreign  matter  under  the  skin  which  is  not, 
in  cases  of  this  kind,  so  readily  absorbed,  giving  during  that 
period  of  time  a  more  pronounced  contour  or  fullness,  which 
passing  away  in  the  natural  course  of  events  does  not  imply  the 
absorption  of  the  matter  injected — a  statement  so  often  made 
by  those  not  in  favor  of  using  parafifines  of  low  melting  points 
for  subcutaneous  protheses. 

Such  result,  however  extensive,  as  it  might  be  in  some  cases 
for  the  lack  of  proper  injection  or  in  the  case  with  oil  injections 
is  at  all  times  correctable,  while  the  hyperplastic  knobs,  so  often 
following  the  injection  of  paraffines  of  high  melting  points  about 
the  shoulder,  can  only  be  removed  by  surgical  means  which  leave 
the  parts  more  unsightly  than  before  anything  had  been  done 
for  the  patient. 


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21.  Parker:  Boston  Med.  (Sr=  Surg.  Jour.,  April  17,  1902. 

22.  Smith,  Harmon:  N.  Y.  Med.  Jour.,  May  17,  1902. 

23.  Hamilton:  La  Rhinoplastie,  Paris,  1904. 

24.  Q\x\n\ai.n:  Laryngoscope,  h.\i^.,  1902. 

25.  Connell:  Jour.  Am.  Med.  Assn.,  Sept.  13,  1903. 

26.  Lynch:  Virginia  Semi-Monthly,  Sept.,  1901. 

27.  Heath:  American  Medicine,  Dec.  7,  1901. 

28.  Roe:  American  Medical  Quarterly,  June,  1899. 


142  HYDROCARBON  PROTHESES 

29.  Eschweiler:  Arch,  fiir  Laryngologie,  Bd.  17,  H.  i. 

30.  Connell:  previous  citation. 

31.  Meyer:  Munchener  Med.  Wochenschrift,  No.  11,  1901. 

32.  Taddei  et  Delaini:  Riforma  Medica,  Nov.  18,  20,  1902. 
2^.  Stubenrath:    Jour.  Am.  Med.  Assn.,  Sept.  19,  1903. 

34.  Straume:  "        "       "  "  "      "       " 

35.  Sobieranski:       "        "       "  "  "      " 

36.  Dunbar:  "        "       "  "  "      " 

37.  Stein:  Berliner  Klinische  Woch.,  S.  840,  1901. 

38.  Smith:  N.  Y.  Med.  Jour.,  May  17,  1902. 

39.  Jukuff :  Arch,  fiir  Experimentelle  Pathologic,  Bd.  32,  S.  124. 

40.  Broeckaert:  previous  citation. 

41.  Wolff:  Freie  Vereinigung  der  Chirurgen,  Berlin,  Dec.  9,  1901. 

42.  Eckstein:  Deutsche  Med.  Woch.,  No.  32,  Aug.,  1902. 

43.  Vassermann:  Beitrage,  z.  Klin.  Chir.,  Bd.  35,  S.  613,  1902. 

44.  Pfannenstiel:  previous  citation. 

45.  Kapsammer:       "  " 

46.  Leiser:  Aertzlicher  Verein,  Hamburg,  Feb.  4,  1902. 

47.  Kofman:  Chirurgie  en  russe,  No.  69,  1902. 

48.  Moskowicz:  Wiener  Klin.  Woch.,  No.  2,  1903. 

49.  Comstock:  Medical  Record,  Nov.  i,  1902. 

50.  Hurd  SaHolden:  Medical  Record,  July  11,  1903. 

51.  Mintz:  Zentralblatt  fiir  Chir.,  Jan.  7,  1905. 

52.  Broeckaert:  previous  citation. 

53.  Brindeh  Presse  Medicale,  Juin  7,  1902. 

54.  Cazeneuve:  These  de  Paris,  Oct.,  1902. 

55.  Stein:  previous  citation. 

56.  Freeman:  See  Connell,  Jour.  A.M.  A.,  Sept.  26,  1903. 

57.  Downie:  previous  citation. 

58.  Alter:  Medical  Record,  Feb.  7, 1903. 

59.  Connell:   previous  citation. 

60.  Eckstein:         "  " 

61.  Paget:  British  Med.  Jour.,  Sept.,  1902. 

62.  Smith: /o«r.  ^.  M.  .4.,  Sept.  26,  1903. 

63.  Quinlan:  Laryngoscope,  Aug.,  1902. 


HYDROCARBON  PROTHESES  143 

64.  Downie:  previous  citation. 

65.  Karewski:  Berliner  Klin.  Woch.,  S.  770, 1902. 

66.  Pflugh:  Deutsche  Med.  Woch.,  p.  422,  1902. 

67.  Cazeneuve:  previous  citation. 

68.  VioUet:  Bull,  de  la  Soc.  de  Chir.,  Paris,  1902. 

69.  Delangre:  previous  citation. 

70.  Ewald:  Centralblatt  jiir  Chir.,  S.  1071,  1902. 

71.  Moszkowicz:  Wiener  Klin.  Woch.,  No.  2,  1903. 

72.  Gersuny:  Centralblatt  fur  Gynakologie,  No.  48,  1900. 

73.  Eckstein:  previous  citation. 

74.  Smith: 

75.  Comstock:       "  " 

76.  Downie:  "  " 

77.  Jukufi: 

78.  Smith: 

79.  Stein: 

80.  Freeman:         "  " 

81.  Wendel:  Berliner  Klin.  Woch.,  No.  41,  1903. 

82.  Hertel:  Grceje  Arch  jiir  Ophalmologie,  S.  239,  1903. 

83.  Comstock:  previous  citation. 

84.  Wenzel:  Deutsche  Med.  Woch.,  No.  21,  1903. 

85.  Eschweiler:  previous  citation. 

86.  Morton:  Am.  Med.,  Oct.  24,  1903. 

87.  Gersuny:    previous  citation. 

88.  Moskovvicz:       " 

89.  Parker:  Boston  Med.  &'  Surg.  Jour.,  April  17,  1902. 

90.  Freeman:  previous  citation. 

91.  Comstock:         "  " 

92.  Downie:  "  " 

93.  Morton:  "  " 

94.  Smith: 

95.  Paget: 

96.  Pfannenstiel:     "  " 

97.  Brceckaert: 
08.  Eckstein: 


144  HYDROCARBON  PROTHESES 

99.  Karewski:  previous  citation. 

100.  Paget: 

loi.  Comstock:  "    '       " 

102.  Smith:     Jour.  A.  M.  A.,  Sept.  26,  1903. 

,__  (<  II       It        <<     ((         a  u  u 

103. 

_„ .  a  u       ii        i(     It         II  a  « 

104. 

105.  Eckstein:    "     "      "    "       "        "        " 

106.  Paget:         "     "      "    "       "        "        " 

107.  Hill:  previous  citation. 

108.  Scanes  Spicer:  See  Nelaton  La  Rhinoplastie,  p.  236,  Paris,  1904. 

109.  Smith:  previous  citation. 

no.  Sebileau:  Bull.  Soc.  de  Chir.,  1903. 

111.  Kofman:  previous  citation. 

112.  Tuffier:  Bull.  Soc.  de  Chir.,  Paris,  April  6,  1903. 

113.  Gersuny:  Zeitschrift  fiir  Heilkunde,  Bd.  i,  Heft  9,  1900. 

114.  Eckstein:   previous  citation. 

115.  Brceckaert:       "  " 

116.  Eckstein:  Deutsche  Med.  Woch.,  Aug.  7,  1902. 

117.  Freeman:  previous  citation. 

118.  Downie:  "  " 

119.  Smith:  Med.  Rev.  of  Rev.,  Nov.,  1902. 

120.  Mayo,  Wm.  J. -.Jour.  A.M.  A.,  Sept.  19,  1903. 


INDEX 


INDEX 


A 

Abscess,  resultant lo,  50,  57,  96 

"  treatment  of 58 

Absorption  of  paraffine.  .9,  23,  32,  118 

"  toxic 9 

Air  embolism 9,  16 

Alae  interference 23 

"     injection  about 23,  1 13 

Alcohol,  use  of 69 

Aldehyde,  formic 11 

Alter 23 

Alumen  acetate 47 

Aluminum,  nasal  splint 14,  98 

Amaurosis,  resultant 17,  19,  131 

Amyl  nitrate,  use  of 19 

Anaemia,  local I3'  49 

Anesthetics,  indication  for,  8,  18,  52,  56, 

72,  76,83,  84,  107 127 

Animals,  injection  into 29 

Antiphlogistine,  use  of 47,  83,  no 

Appearance,  secondary  mass 54 

Application   of   cold,    22,    44,    47,    76, 

.103 122 

Aspiration  of  wound 59 

Asthesia  of  skin 43 

Auricular  deficiency 80,  135 

Avoidance  of  hyperinjection 22 

B 

Baratoux 2 

Behavior  of  new  tissue ^3 

Benzine   solvent 15 

Bichloride  of  mercury,  use  of 69 

Blepharoplasty 88,    127 

Blindness,   resultant 17,   19,  131 

Bloodvessels,  compression  of .  ...  21,  43 
"  injection  into 37>  55 


Blunt  needles,  use  of ..  .21,  56,  103,  128 

Body  weight,  loss  in 10 

Boric  acid,  use  of 68 

Breast,  injection  into 30,  58 

Bright's  disease,  contraindication  in.  .12 

Brindel 2,  20 

Brceckaert 2,  11,  20,  35,  64 

C 

Canula 59 

Casts,  plaster 91 

Cause  of  pigmentation 55 

"        "  redness 46 

Celloidin,  use  of 22 

Cellulitis 136 

Cephalagia 43 

Cheeks,  deformities  about 79,  123 

Cheyne 2 

Chin,  deformities  about 80,132 

Chloroform  solvent 15 

Choice  of  melting  point,  35,  36,  87,  88, 

92 lOI 

Circulation  in  skin 12,  44 

Classification  nasal  deformities,  4,  78,  90 
Cocaine,  anesthetic  use  of,  8,  18,  72,  131 
Cold  applications,  22,  44,  47,  76,  103, 

122 

"  mixture,  use  of,  21,  22,  26,  39,  41, 
45,49,51,92 lOI 

"    preparation 37,  39,  41 

"    preparations,  safety  of.  .  .  .38,  131 

Collapse  of  alae 23 

"        post  injectio 17 

"        of  retinal  artery 19 

Collodion,  use  of,  22,  25,  76,  108,  122, 

135 
Comstock 18,  29,  31,  35)  36 


148 


INDEX 


Connective  tissue,  appearance  of ....  54 
"  "      formation  of ..  28,  30 

"  "      influenced  by .  .  34,  38 

"  "      removal  of 43 

Connell 2,  9,  24,  46 

Continuous  current,  use  of 15 

Contraindication 47 

Corning i 

Cosmolin,  use  of 38 

Curette,  use  of 52 

Current,  electrical  use  of .27 

Cystic  evacuation 29 

D 

Death  by  embolism 56 

Decazeneuve 20,  27 

Deficiency  alar 113 

"  cheek 123 

"  forehead,  intercilliary..  .  .85 

"  "         lateral 84 

"  inferior  half,  nasal 99 

"  inferior  third,  nasal 95 

"  interlobular,  nasal in 

"  labial 115 

"  medium  third,  nasal.  .  .  .94 

"  superior haK  "    ....97 

"  "         third,      "    ....92 

"  total  anterior         "    ...103 

Deficient  forehead 83 

Deformities  about  cheeks 79 

"  "      chin 80,  132 

"  "      ears 80,  135 

"  "      forehead  ..."...  .77 

"  "      mouth 79,  115 

"  "      nose 4,  78,  90 

"  "      orbit 79,  126 

"  "      shoulders.  .  .80,  138 

Delain 10 

Delangre 1,27 

Dense  tissue,  injection  into 9,  12 

Depression,  forehead  transverse ....  82 

"  linear  forehead 82 

"  punctate  forehead 82 

Diabetes,  contraindication  in 12 

Diffusion,  primary 9,  21,47,  ^04 

"         secondary.  .  10,  47,  48,  50,  51 

Digitalis,  use  of 19 

Diminution  of  prothesis 32,  108 


Dissection,  subcutaneous .  8,  12,  13,  52, 
75.  76,  83,  84,  94,  96,  98,  loi .  .  104 

Downie 2,  22,  26,  30,  35,  64 

Drainage  of  wound 59 

Dressing  of  wounds 53,  76 

Dunbar 10 


Ears,  deformities  about 80,  135 

Ecchymosis 49, 97 

Eckstein.  .2,  13,  25,  28,  30,  35,  36,  45, 

60 64 

Electric  current,  use  of 27,  39,  56 

Electric  paraffine  heater,  Kolle 40 

Electrolysis,  indication  for.  15, 40, 56, 1 12 

Electrolytic  scarring 16,  56 

Elimination  of  parafiine,  primary .  9, 49, 

96 1 24 

Elimination  of  paraffine,  secondary. .  58, 

75,  96,  109 115 

Embolism,  air 9,  16 

"  death  by 56 

"  paraffine 9,  16 

"  pulmonary.  .....  .2,  18,  56 

Encapsulation  of  mass 13,  28 

Encystment  of  mass 13 

Epicanthus 93 

Escape  of  paraffine 9,  24,  29 

Eschweiler 8,  31 

Ether  solvent 15 

Etherization,  objection  to 72 

Ethyl  Chloride  spray,  indication  for .  8, 

56,73.122 139 

Eucaine  anesthetic. 8,  52,  72,76,83,84, 

107. 131 

Evacuation  of  cyst 29 

Ewald 27 

Extirpationof  mass.14,  30,  43,48,  52,  54 


Facial  deformities 77,  82 

Fibromatosis 50,  53 

Filling  method 7 

Fining  of  syringe.  .  .  .16,  25,  28,  39,  70 

Fistula,  secondary 50 

Forehead,  deformities  about 77 

"  deficiency 83 


INDEX 


149 


Forehead,  depression,  punctate 82 

"  depression,  transverse. .  .  .82 

"  receding 83 

"  "        lateral 84 

Forensic  notes 6 

Freeman 21,  30,  35.  64 

Frown,  injection  for 85 

Furrow,  naso-labial 119 

Furrow,  oral 122 


Gangrene.  .9,  11,  13,  52,  57,  96, 102,  109 

Gangrenous  absorption 32 

Gersuny i,  28,  29,  32,  35,  38,  60 

"      method 2,  8,  33 

"  "      of  preparing  paraffine  38 

Growth,  appearance  of 54 

"        histological  examination  of  30, 

31 

"        influences 34)  3^ 

"        limitation 34 

"        of  mass 30>  34 

"        removal   of 43 

Guiaform,  use  of 11 


H 


Halban i 

Hamilton 2 

Hart  paraffine 2,  29,  45,  114 

"  "        objection  to 36 

Heater,  paraffine 26 

"  "       Kolle 39 

"  "        Smith 41 

"  "        Quinlan 27 

Heath 2 

Hertel 30 

Hill 2,  49 

Histological     examination    of    growth 

30 31 

Holden 18 

Hook  nose 99 

Hot  water,  use  of 26 

Hurd 18 

Hyperaemiaof  skin 10,  44,  45,  1 12 

"  "  cause  of.  .46,  102 

"  "  treatment  of .  .  .47 

Hyperinjection 9,  12,  14,  20,  21 


Hyperinjection  avoidance  of 22 

"  cause  of 25 

"  of  vaseline 15,110 

Hyperplasia  of  tissue.  .  .  10,  50,  53,  107 
Hypersensitiveness  of  skin 10,  42 


Ice  cloths,  use  of .  .  .  .22,  44,  47,  76,  103 

Ichthyol,  use  of 47 

Idiosyncrasy  of  tissues 53 

Indication  for  injection  specific 77 

Indication   for  protheses 2 

Infarction,  pulmonary 20 

Infra  orbital  injection 21 

Infection n,  24 

Influence  on  growth 34>  3^ 

Injection  about  alae 23,  105 

"  "     chin 22 

"  "     mouth 22,  115 

"  "     nose. . 24,  29,  85  to  115 

"  "     neck 56 

"  "     orbit 126 

"         amount  of ..  12, 83,  84,  85,  96, 

106 109 

"         infra  orbital 21 

"         into  animals 2 , 

"         practical  technic .  .  .  73,  86,  87 

89, 104 106 

"         sterile  water I3>  95 

Injury  with  needle 25 

Immobility  of  skin 24 

Instruments,  use  for 60 

Insulation  of  needle 25 

"  "   syringe 60 

Intercilliary  furrow 85 

Interference,  muscular 23 

"  of  alar  action 23 

"  respiratory 23 

Intoxication,  resultant 10 

Intracutaneous  injection.  .  .  .12,  18,  20 
Intraneedle  soUdification 25 


J 


Jukuff. 


10,  30 


K 

Kapsammer i,  17 

Karewski 2,  27,  35 


ISO 


INDEX 


Knife  edged  needles 21 

Kofman 18,  56 

Kolle  electrothermic  heater 39 

"      mixture  of  cold  paraffine 39 

"      screw  drop  syringe 61,  63 

L 

Labial  deficiency 115 

Lake .  .2 

Lateral  deficiency,  forehead 84 

Leiser 17 

Linear  depression,  forehead 82 

Liquid    paraffine,   contraindication,    45, 

47. 

Liquefication  of  paraffine 25,  26 

Listerine,  use  of •  ■  .  .  68 

Lobular  insufficiency,  nasal 1 08 

Local  anesthesia.  .  .8,  18,  52,  56,  72,  76 

Local  untoward  results 10 

Lynch 2 

M 

Malformation,  post  injectio 7 

Mass,  growth  of 3°)  34 

"      moulding  of,  24,  56,  74,  84,  87,  89, 

92,  93,  95,  96,  loi,  117,  120, 

124 

Mass,  removal    of,   30,  43,  48,   52,   54, 

103,   108 Ill 

Massage,  secondary 126 

Mayo 75 

Melting  point,  choice  of,  35,  36,  87,  88, 

92 lOI 

Melting  point  of  cosmolin 38 

Melting  point   of  paraffine,   10,   12,  18, 

20,  34,45.  47.89 Ill 

Melting  point  of  vasehne 38 

Mercury,  bichloride,  use  of 69 

Method,  advantage  of 8 

"        filling 7 

"        Gersuny 2,  8 

Meyer 10 

Mintz 19 

Mixture  cold  paraffine,  use  of,  21,  22, 

26,  39,  41,  45,  49,  51,  92,  96.  .  .101 
Mixture  paraffine  and  vaseline,  Kolle. .  39 
Morton 33,  35 


Moszkowicz 2,  18,  27,  35 

Mouth,  deformities  about 79,  115 

Movement  of  parts  injected.  .  .  .29,  116 

Muscles,  paralysis  of 19 

Muscular  action,  interference  with .  .9,  23 
Muscular  deficiency,  temporal 88 

N 

Nasal  deficiency,  alar 113 

"  "         ant.  total 103 

"  "  inf.  half 99 

"  "  inferior  third 95 

"  "  interlobular iii 

"      "    med.  third 94 

"     "    subseptal 114 

"      "    sup.  third 92 

"      deformities 4.  78,  90 

"      insufficiency,  lateral 105 

"  "  lobular 108 

"      splint 14,  98,  102 

Naso-labial  furrow 119 

Necrosis 9,  1 1 

Needles,  blunt  pointed.  .  21,  56, 103,  128 

"        infection  by 24 

"        injuries  by 24,  86 

"       insulation  of 25 

"        occlusion  of 25 

"        solidification  in 26 

"       use  of,  21,  55,  66,  84,  86,  93, 

96,  97,  104,  105 128 

Needles,  knife  edged 21 

Neuroses,  secondary 44 

Nose,  injection  about 24 

Numlaer  of  sittings,   12,   55,  74,  82,  85, 
89,  94,  96,  122 139 

O 

Occlusion  of  bloodvessel 103 

"  of  needle 125 

Ocular  stump,  deficiency  of 130 

CEdema n,  43,  51,  85,  128,  140 

Oil,  sperm 128 

Oils,  mixture  of 50,  88 

Oil,  subcutaneous  use  of.  .1,  50,  88,  128 

Oral-angular  furrow.  ., 122 

Orbit,  deformities  about.  .  .79,  126,  129 
"      venous  congestion  of.  .  .  .19,  128 


INDEX 


151 


Paget 26,  35,  36,  45 

Paracentesis  knife,  use  of 75 

Paraffine,  absorption  of 9,  28,  32 

"  cooling  of 25 

"  escape  of 9.  24 

"         "  Hart  " 2,  29,  45,114 

"  heater 26,27,39,41 

"     Kolle 39 

"  "      Quinlan 26 

"  "     Smith 41 

"  liquefication  of 25,  26 

"  melting  points,  10,  12,  17,  18, 

20,  23,  27,  29,  30,  34,  35, 

36,  41,45,47,89 III 

"         mixtures...  .21,  22,  41,  45,  51 

"  plates,  use  of 109 

"  screw  drop  syringe,  Broec- 

kaert 64 

"  screw  drop  syringe,  Dow- 

nie 64 

"         screw  drop  syringe,  Eck- 
stein   60 

"         screw  drop  syringe,  Free- 
man   64 

"         screw  drop  syringe,  Kolle 

61 63 

"  screwdropsyringe, Smith.  .64 

"  solidification •  .    9,   25 

"  solvents 15 

"  temperature  of 12,  13 

Paralysis,  muscular 19 

Parenchymatous  injection.  ...  12,  18,  20 

Parker 2,  35 

Perichondritis 107 

Peripheral  union 13 

Pfannenstiel 2,  17,  18,  35,  36 

Phlebitis 19,  20,  37,  48,  56,  85,  107 

Pflugh 27 

Photography,  use  of 91 

Pigmentation,  cause  of 55 

"  of   skin,    10,   36,    51,   54, 

118 127 

Plaster  casts,  use  of 91 

Plasters,  use  of 15,  76,  98,  108 

Post  operative  collapse 17 

"  "  reaction 9,  20,  49 


Practical  technic,  72,  89,  104,  106,  118, 

133 

Pravaz  syringe i,  25,  60 

Precautions  for  injection 5 

Preparation  of  cold  mixture,  Kolle.  .39 
"  "      "  "         Smith.. 41 

"  "  instruments 70 

"  "   paraffine,  Gersuny.  .  .38 

"  "   site 68 

Pressure  necrosis.  .  .  .9,  11,  13,  62,  109 

Primary  diffusion 9,  21,  47 

"         elimination 9,  49,  96,  124 

Proper  melting  point  of  paraffine .  .  34, 36 

Protheses  diminution 32 

"  indications  for 2,  90 

Ptosis,  resultant 87 

Pulmonary  embolism.  .2,  18,  19,  20,  56 

Punctate  depression,  forehead 82 

Puncture  into  vein 20 

Q 

Quantity,  injection  of 14,  52,  74 

Quinlan 2,  26 

Quinlan's  paraffine  heater 27 

R 

Rabbit,  injection  into 29 

Reaction 11 

"        post  operatio 9,  20,  49 

Receding  forehead,  treatment  for.  .  .83 

Redness  of  skin 10,  44,  45,  1 12 

"         "     "    cause  of 46,  112 

"        treatment  for 47 

Removal  of  mass.  .  14,  30,  43,  48,  52,  54, 

103,  108 Ill 

Replacement,  post  injectio 11 

Respiratory  interference 23 

Results,  untoward 9 

Resultant  abscess 10,  50,  57,  96 

Retinal  artery,  collapse  of 19 

Rhinoplasty,  comparison  to 90 

Roe 4 

Rohmer i 

S 

Saddle   nose 94 

Safety  of  cold  preparations 38 


152 


INDEX 


Scarring  of  skin,  electrolytic.  .  .  .  i6,  56 

Schleich  mixture,  use  of 76 

Sebileau ^3 

Secondary  diffusion .  .  .10,47,  48,  50,  51 

"         elimination 58,  75, 96, 

109.. 115 

"         fibromatosis 5°)  53 

"         fistula 50 

"         mass,  appearance  of 54 

"         massage 1 26 

"         neuroses 44 

"         traumatism 58 

"         treatment 93,  95 

Semisolid  mixture 26 

Shoulders,  deformities  about.  .  .80,  138 
Sittings,  number  of.  .12,  55,  74,  82,  85, 

89,  94,  96,  122 139 

Skin,  asthesiaof 43 

"       burning  of 37 

"      circulation  in 12,  44,  48 

"      hypersensitiveness  of 10,  42 

"      redness  of 10,  44 

"      tattooing   of 57 

"      yellow  pigmentation,  cause  of. .  55 
of.. .10,  36, 

,    51 54 

Sleeve,  electrothermic 27 

"       insulating 26 

Sloughing  of  tissue .  9, 12,  13,  57,  96,  102 
Smith .  2,  ID,  26,  29,  30,  35,  40, 43, 44, 45 

Snout  nose 99 

Sobieranski 10 

Solidification  of  paraffine 9i  25 

Solvents  of  paraffine 15 

Specific  classification  for  injection ...  77 

Spicer 2,  51 

Splint,  nasal 14,  98,  102 

Stein I,  10,  21,  30 

Sterilization  of  mass 11 

Straume 10 

Stubenrath 10 

Subcutaneous  dissection.  .8,  12,  13,  52, 
75.  76,  83,  84,  94,  96,  98,  loi,   114 

Subinjection 9,  14,  129 

Subseptal  deficiency 114 

Suppuration,  secondary 5°)  57 

Suture  silk 8,  52,85, 108,  114 

Syringe,  Broeck^rt 64 


Syringe,  Dovrnie 64 

"       Eckstein 60,  64 

"       filling  of 16,  25,  28,  39,  70 

"        Freeman 64 

"       holding  of 16 

Kolle 61,63 

"       Pravaz i,  25,  60 

"        Smith 64 

Systemic  untoward  results 10 


Taddei 10 

Tattooing  of  skin 57 

Technic,   practical.  .  .  .72,  89,  104,  106, 

118 133 

Temporal  deficiency 88 

Thermophorm,  sleeve 27 

Thrombosis 18,  37 

"  death  by 18 

Time  required  for  development  of 

new  tissue 33 

Tissue,  density  of 12 

"       growth  influenced  by 34 

"       hyperplasia  of .  .  .  10,  50,  53,  107 

"       idiosyncrasy 53 

"      loss  of 9 

"      replacement 1 1>34 

Traumatism,  secondary 58 

Treatment  for  hyperplasia 47 

"  "    secondary  abscess ....  58 

"        secondary 83,  85 

Trocar,  use  of 59 

Tuffier 58 

Tumefaction  of  injected  site.  ...  14,  50 

Tumor,  electrolysis 16 

"       removal  of .  .  .  14,  30,  43,  48,  52 
"        secondary 43 

U 

Union,  peripheral 13 

Untoward  results,  local 10 

" 9 

"  "        systemic 10 

Use  of  cold  applications,  22,  44,  47,  76, 
103 122 

Use  of  needles,  21,  55,  66,  84,  86,  93, 
96,  97,  104,  105 128 


INDEX 


153 


V 

Vaseline,  hyperinjection  of 15,  no 

"       injection  of .  .  i,  23,  49,  51,  89, 

109,  II  1, 1 13 121 

"       melting  point  of 38 

"        mixture  of 38,  49 

"       retention  of  shape 23 

Vassermann 15 

Vein,  injection  of 20 

"     occlusion  of 103,  1 10 

"      puncture  of 20 

Venous  arch,  nasal 43,  85 

"       congestion  of  orbit 19 

Viollett 27 

Von  Frisch i 


W 

Water  bath,  use  of 12 

"       sterile  injection  of i3)  95 

Weight,  loss  in  body 10 

Wendel 30 

Wenzel 31 

Wound,  aspiration  of 59 

"      drainage 59 

"       dressings 53>  7^ 

X 

Xanthalasma 55, 127 

Xycol  solvent 15 

Y 

Yellow  pigmentation  of  skin.  ...  10,  36, 
5I'  54 118 


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